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9__ ��AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
' REQUESTING DEDUCTION FROM ASSESSED VALUATION
\ � � / State Fortn 43708 (R4 / 10-Ot )
Prescribed by the Department of Local Govemment Finance
�naGOn contained in this document is CONFIDENTIAL pursuaN to IC 6-1.1-12-9.
COUNTY TOWNSHIP YEAR
File Mark
INSTRUCTIONS: FILING DATES:
To 6e filed in person or 6y mail with the CountyAuditor of the county where 1) Real propeity: During the 12 montYs 6efore May
the property is locafed.
11 0/ the year the deduction is to be effective.
2) Mobile homes assessed under I.C.6-1-1-7;
See reverse side Ior additional insWction and qualifications. befween Ja�uary 15 and Maroh.31 of the year
the d�ctiq.h is.nto be ��ctivB. �l
1� �L.i IdJ 1Lf
Name of applicant (ow or wntracf rJ � �,<(�y�� `^' vUG
� AF'K 0 � 2003
i
Is applicant the sole legal or equitable ovmer? If No, what is hisAier exact share or interest? , owned with sbme"oAe other �t7an ;pouse,
name on
:51ifiF-Sni
district
residence?
Yes ❑ No
below
musf bave been buying on conhact at least one
Key number I legal
❑ Yes ❑ No
the applicant 65 years o( age or more on December 31 of ihe year
to Ihe current year?
�IicanYs date of birth
ed by a surviving, w
time of deafh?
❑ Yes � No
day, year)
spouse, what was lhe spouse's age at
you filed tor any other deductions?
you filed (or deductions in any
❑Yes ❑No
county?
GI3SON COU� iY AUDI
Is lhe property in question:
❑ Real property ❑ Mobile home (I.C. 61-1-n
Assessed vaioe�of the property as of March 1, wrrent year (may not
exceed 869,000)
Does the combined annual adjusled gross incor
individuals sharing ownership exceed 525,000?
Source of lneome
If Yes, what deductions?
$
$
TOTAL $
and any
❑ Yes ❑ No
Amount of Income
❑ Yes ❑ No �
INJe certify under penalty of perjury that ihe above and foregoing information is irue and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned propeAy on March 1, 20 _
Signature of applipnt n Signature of authorized representative (by executed Power o(Attomey)
7� / �° CL� �' �