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� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rv TOWNSNIP vEaa
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S � State Fortn 43708 (RS / 6-03)
�a�
PfascriEed Dy Ue Department of Laal Govemment Finance �j �� f� 1� �� �
`' � File Mai1cJ
Informafion contained in Nis document is CONFIDENTIAL pursuant to IC &1.1-12-9. � ��--� -"
�'TRUCTIONS: FILING DATES:M4`( 2 (�, ZUO4
To be filed in person or by mail with the County Auditor o/ fhe counry where 1) Real property: During the 12 months before May
the property is Ixated. 11 01 the year fhe deduction is to�be effective.
2) Mo6ile homes a`ssessed:'under-l�ES6-Y-1-7;
rymg on contract at �east one (7) year)
Key number / Legal description
r�/ 0"1= 000�a—�
Assessed'value ol
exceed $144,000)
❑Yes ❑No
Was the applicant 65 years of age or more on December 31 of the year
pnor to the current year? ��
LlfYes ❑ No
the Gme ot death?
you filed for any oiher deducUons?
Y�
age
❑Yes ❑No �
any other county? If Yes,
Q
combined
s sharing
�P ��-C�-fo
i someone other ihan spouse,
whom
Is the property in quesuon:
ld'Real property ❑ Mobile home (I.C. 6-1-7-7)
property as
�
❑ Yes ❑ No �
I/We certify under penalty of perjury lhat the above and foregoing information is true and correct and Ihat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
' / �
Address o( a(7plicani �Address of auihorized representative
(by executed Power olAttomey)