Age_Elderbrook��'n § AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'r� REQUESTING DEDUCTION FROM ASSESSED VALUATION
��� State Fartn 43708 (R6 / 4-04)
Prascribed by ihe Department o( Local Govemment Finance
InformaUon contained in this document is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-1.1359.
COUNTY TOWNSHIP YEAR
File Mark
INSTRUCTIONS: FILING DATES:
To be filed in person or by mail with the CountyAuditor of the county where 1) Real property: During the 12 months before May
the property is located. 11 0l the year the deduction is to 6e effective.
h es erl.C.6-1-1-7;
See reverse side !o� additlonal instruction and qualifications. ��n anua a rch 31 of the year
e i �ve.
Name ot appliwnt (o er convac� "-_ _- FEB 1 8 2005
` ��
Is applicant fhe sole legal or equitable ovme� If No, what is his�her exact share or interest? If� w�� th_wh ne other than spouse,
� GIB aN Cpb NTY DITOR
❑ No
If name on rewrd is difterent than fhat oi aoolicant. indicate below
on conNact at
�so�aUS�
[�Yes ❑ No
fhe applicant 65 years o( age or more on December 31 of the year
to the cunent
/ es ❑ No
� -as 3g
I( filed by a surviving, unmarried spouse, what was the spouse's age at
the time oi death7
you
Have you
any
O Yes
❑ Yes
one
Is lhe property in quesUon:
❑ Real property � Mobile home (I.C. Ef-1-�
:d value ot the property as
$144,000J
year
INVe certify under penalty of perjury that the above and foregoing information is true and conect and that lhe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
gnature of applicant Signature of authorized represenfative (by executed Power olAttomeN
Ii; � �• Y�-L
ofapplicani
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