Age_Kramer" AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
x-; REQUESTING DEDUCTION PROM ASSESSED VALUATION
f State Fwm 43708 (R3 / 8-00)
'•'• Prescribed_by the State Board ot Tax Gommiuioners
Infortnation contained in Nis document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS FOR FILING:
To be (led in person or 6y mail with the County Auditor of the county where the property is loca-
ted during the 12 months be%2 May 11 of the year the deduction is to be effective.
Deductions (ormobile homes not assessed as 2a1 property must �le between January 15 and
March 31. � �
See reverse side (or additional instruc6on and qualifications.
COUNTY I TOWNSHIP 1 YEAR
F,� �
��
MAY 0 � 2003
`�j \ kUD�
Gt850N COUt T .
Name of applicant (ownerorcontrac(,puyer „ .
��
Is applipnt the sole legal or equitable ownerl If No, what is h�sRier exact share or interest9 If owned with someone other than spouse,
indicate with whom
❑ Yes ❑ No
If name on record is different than that of applicant, indipte below .
Name of conVad seller (applicant musf have been buying on contract at least one (1) yea�
Address of contrad seller
ing dis id Key number / Legal description Record number Page number
. /� =WOC��CD=`-.C'7 .
Is the real property used and occupied Kssessed value of the property as of March 1, wnent year (may not
primariy for hislher residence? exceed $69,000) �.l
�s ❑No � �O V
Was the appliwnt 65 years of age or more on December 31 of Ne year • Does Ne combined annual adjusted gross income of the applicant and any
prior to the wrrent yearl individuals sharing ownership exceed 525,0007
es ❑ No ❑ Yes �
ApplipnYs date of birth (month, day, yea� Source of Income Amount of Income
�- -� Ss $
I( filed by a surviving, unmarried spouse, what was the spouse's age at $
the Gme of deatt�?
TOTAL $ /�
Have you filed for any other deductions? If Yes, what deductions?
�s ❑ No
Have you filed for dedudions in any other county7 If Yes, what county?
❑ Yes U3'No
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 1, 20 _
Sign re of appiiwnt Signature of authorized representative (by executed PowerofAttomey)
j' �G,_.(il�� �'c . M.,......� .
.dr s of appliwnt Address of authorized representative �
�,�Q MQ� s+ �ati6s�4J+ s,�