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3._ 2� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�' ' REQUESTING DEDUCTION FROM ASSESSED VALUATION
'� �N ! Slata Fortn 43708 (R4 / 70-Ot ) � {�
� Prescribed �y Ne Depanmenl of Local Govemment finance \�,/
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9. ,� Y
INSTRUCTIONS: "
To be fled in pe�son or 6y mail with the County Auditor oI the county where
the p�operty is locafed.
See reverse side /or addftional instruction and qualifications.
COUNTV TOWNSHIP YEA
� 0�
File Mark
FILING DATES:
1) Real property: During the 12 months be(ore May
11 0! the year the deducfion is to be effective.
2) Mo6i/e homes assessed under I.C.�1-1-7;
befween January 15 and March 31 of the year
fhe deduction is to be effective.
Name of appf t(ownei oi conf 1 b�rJ
/s 7�C%ti��
Is appli uitable o ner? If No, what is hisAier exact share or interest? If owned with someone other than spouse,
indicate with whom
❑ Yes ❑ No
If name on record is difterent than that of applicant, indiwte below
Name of contrad seller (app/icant musf have been buying on confract af least one (1) yearJ
Address of conVad seller Is the property in quesiion:
�.Real property ❑ Mobile home Q.C. E74-�
�ng district Key number / Legai desaiption Rewrd number Page number
�t-�=�bo�9--er?
Is the property used and occupied primarily for Assessed value of the property as of March 1, currenf year (may not
hislher residence? ezceed $69,000)
Yes ❑ No �
Was the applipnt 65 years of age or more on December 31 0( fhe year poes the combined annual adjusfed gross income of fhe applicant and any
prior to ihe wnent year? individuals sharing ownership exceed $25,000?
es ❑ No ❑ Yes ❑ No
ApplicanYs date of birth (month, day, yearJ
$
Have you filed for any other deduc6ons? If Yes, what deduUions?
❑ Yes ❑ No
Have you filed (or deducGons in any other county? If Yes, what county?
❑ Yes ❑ No
INVe certify under penalty of perjury that lhe above and foregoing intormation is lrue and correct and lhat the applicant was a resi-
dent of Indiana and owner of lhe aforementioned property on March 1, 20 _
Signature of applica Signature ot autho�zed repfesentative (by executed Power ofAttomey)
ress f pplicant p� I n d J�) � Address of aulhorized representative
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