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! AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MOR.E, couNrr TOWNSHIP reo,R
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
S SUte Fwm 43708 (RS / 6-03)
u�•
PresttiDed by Ne Department of Lorai Govemment Fnance
mation conWined in this tlocument is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o/ the county where
the property is locafed.
See 2verse side /or additional instruction and qualifications.
Name of applicant (owner or o tract buye�
/� � , 1) ip �,,:_ �� ^ `� J
�.l�vc-i"�� - ��? 1
Is aoolicant the sole leaal or eouitable owneG� If No, what is hisRier exiac —share or
I�fes ❑ No
If name on record is difierent than that of aoolicant, indicate below
wntract
conVact seller
must �ave been buNno on contlact at least one
File Mark
� 'T •�""'9 T"'1�
FILING�DATES: ' �� �
1� � 1�_{ _�1
1) Real property: Dunng the 12 months 6elore May
11 of the year�the.deduction is to 6e effective.
2) Mo6ile homes assesse��nder I.C.6-1-1-7;
between January 15 and March 31,o(the year
the�deduction is`to be eflecti✓e. ��
i.1^ =^-^.�'i; � . , l�i�c....., .
� . .,�. „- - .. ._ ,.,. ,
u ownea wiin someane
indiwte vriN whom
Is the property in quesiion:
spouse.
�' Real property ❑ Mobile home (I.C. 6-7-1-n
Ta�cing distnct Key number / Legal descriplion Record number Page number
lt.arn��cn �c�=/-a--000=� � �
�e property used and occupied primarily for hssessed value of Ne property as of March 1, curtent year (may not
�s/her residence? exceed $144,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the arrent year? individuals sharing ownership exceed 525,000?
�} -
spouse's age al
❑ Yes o
❑ Yes �o
what
whatcounry?
❑ Yes 0 No
� $ �-,
IIWe certify under penalty of perjury that the above and foregoing information is true and conect and that the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20 _
= of appliwnt
� ��i
of applirant
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