Age_Seifers' rt•. AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP vea.R
7Y"' ' s
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
�` ,��� � SWte Form 43708 (R6 / e-0a) �
Prascribed by ihe Depanment af Local Govemment Finance
� il k
Tormation contained in this document is CONFIDENTIAL pursuant to IC 6•1.1-12-9 and IC 6-1.1-35-9. - �-
INSTRUCTIONS: FILIN�T�'� � �/
To be filed in person or by mail with the CountyAuditor of the county where 1) Real property: During the 12 months belore May
the property is located. 17 o/the �(1p��h�d�da� is to be eHective.
2J Mobile homes assessed under 1.C.6-1-1-7;
See reverse side !or additional instruction and quali�cations. befweenJap,yary 15�pd March 31 of the year
the deduotj6fr4����?'c�`fyective.
AUDITOR
Name
�
Name of contracl seller (applicant must have 6een buying on contract atleast one (i) yearJ
Address of contract seller Is the pr erty in question:
Real property ❑ Mobile home (I.C. 6-7•7-7)
T g district Key number! Legal description Record number Page number
� '���� a�-�.�-�q-��_000.�s
is the property used and oCCUpied primarily for Assessad value of the property as of March 1, current year (may not
hislher residence? exceed 5744,000J
Yes ❑ No
Was the applicant 65 years ot age or more on D cember 31 of the year poes the wmbined annual adjusted gross income of the applicant and any
prior to the current year7 individuals sharing ovmership exceed 825,000?
Yes ❑ No O Yes ❑ No
ApplicanPs
❑Yes ONo
Have you 61ed for deduc6ons in any other county7 If Yes, what wunry?
❑Yes ❑No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
• Signature of applicant Signature of authorized represenlative (by executed Power olAttomeyJ
ress of ap ant Address of authorized representative
CO