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� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' State Fwm 43708 (R5/6-03)
Prescnbe0 Ey Ue Department of Laal Govemment Fnanca
�-`^nnation contained in this document is CONFIDENTIAL pursuant to IC 61.1-12-9.
�RUCTfONS:
To be filed in person or 6y mail with the County Auditor o/ fhe county where
the propeRy is located.
See reverse side /or additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
�'-�I�� F, ��
� _File�Mark� (f fJ
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FILING DATES: `�U� 1 6 2004
1) Real property �Dunng the 12 monUu before May
i f of the year the deducfionis to tie effective.
i�� . �. i,
2) Mo6ile hames assessed und'er'I:C:6c,1�,1=7;
between January'15 and'Maicfi'31,of,the year
the deduction is fo be eflective. �
Name of applicant (owner or wnt2ct buyer) ,
. '�'._ � /
— �V
Is applicant lhe sole legal or equitetile owneL� If No, what is hisRier exact share or interest? If owned vrith someone other than spouse,
indicate with whom
❑ Yes o
If name on record is difterent lhan Nat of applicant, indicate below _
Name ot conUact seller (applicant must have been buying on contract at least one (1) yearJ
Address of conVad seller Is the property in questlon:
Real property ❑ Mobile home (I.C. 6-1-1-�
Taxing district Key number / Legal description cord number Page number
� CO_- - --
e property used and ocapied primarity for Assessed value of the property as oi March 1, curtent year (may not
er residence? exceed 5144,000)
s ❑ No
Was the applicant 65 years of age or more on December 37 oi the year poes the combined annual adjusted gross income of the applicant and any
prior to Ne curtent year? individuals sharing ownership exceed 525,000?
�es ❑ No ❑ Yes ❑ No
Applicant's date of birth (month, day, year) Souree ot Ineome Amount of Income
, TOTAL 5 �
Have you filed for any oNer deductions? If Yes, what deductions?
es ❑ No
Have you fiied for deductions in any other counry? If Yes, what counry? ,
❑ Yes o
I/We certify under penalty of perjury that the above and foregoing information is true and correct and thai the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature f applicani Signature of authonzed representadve (6y executed Power otAttomeyJ
re o( applicant Address of auihorized rep25entative �