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dj R�"vt AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE� Courm TOWNSHIP YEAR
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
��• � = Sta;e Form a3708 (R / 9-96)
`�"�' Prescribed by �he Sta:e 9oard of T� Commissioners �.�
Information coniained in this document is CONFIDENTIAL pursuant ro IC 6-1.7-72-9. le ar �
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor o! the county where the property is loca-
ted during the l2 months be%re May 7 7 0/ the year the deduction is to be eflective_
Deductions for mobile homes not assessed as real property must lile between January 75 and
March 31.
See reverse side for additional instruction and qualilications.
APR 19 1999
`�i
GBSON �''J,�
CUU� TY AUDITOR
Name
o. wnai' his/her exaci share of inte It owned with someone other than spouse,
� indicate with whom
B'Yes ❑ No
If name on record is dittereni than that of applicant indicate below
Name ot contract seller (applicant must have been buying on contract at /easf one (7) year)
Address of contract seller
Taxing district Key number / Legal description Record number Page number
CL�.� � � �� D/3 - ��c�
Is the property used and occupied pnmarily tor Assessed value of ihe property as ot March 1, curtent year (may no1
hislher residence? exceed $27,000)
❑ Yes ❑ No ❑ Yes ❑ No
Was the applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ownership exceed 520.000?
❑Yes ❑No
Applicant's date of birth ( n1h, day, yearJ
Have you filed for any other deductions? If Yes, what deductions?
�s ❑No ��'
Have you filed tor deductions in any oiher county? If Yes, whai counry?
❑ Yes C•�IQo
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 7, 19
Signature of applicant Signature of authorized representative (by executed Power ol Attomey) �
�C "l L �� ,
�ress of applica Adtlress of authorized representative
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