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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
� �w � State Fo`m 43708 (R4 / 10-01)
•� Prescrfied by Ihe Department of Local Govemmenl Finance
•
Infortna6on wntained in Ihis dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in person o� 6y mail with the CounfyAuditor of the county where
the p�operty is located.
See reverse side for addifional instruction and oualifications.
COUNTY TOWNSHIP YEAR
File Mark
FILIN gp
1) Re p�rty�urjn th 1 mo hs 6efore May
11 the r`�de uc ion is to 6e ef(ective.
2) between VShLar�' S�3rtVfifa ch/31 of the year
the duction is to be'e8ective.
i � , 0
Name of appliwnt (ownerorwntract buyer) <<-w�!f+'VY- - " =' ' 't
n GIBSON C'vU?Jl i AUD;iCri 1
Is applicanl the sole legal or equitable owner? If No, vfiat is his/her exact share or in st? If owned with someone olher lhan spouse,
indicate with whom
❑ Yes ❑ No
If name on record is diflerent Nan thal of applicant, indicate below
Name of contracl seller (applicanf must have been buying on contract at least one (7) year)
Address of conVad seller Is the property in questio�:
❑ Real property ❑ Mobile home Q.Q 61-1-�
`ng district Key number / Legal descripfion Record number Page number
i
� -- =ao�S3 � �
Is Ne property used and occupied primarily for Assessed value of the property as of March 1, currenl year (may not
hismer residence? exceed $69,000)
�Gres ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to ihe wrtent year? �� individuals sharing ownership exceed 525,000? � �
p1Yes ❑ No LN�o
ApplicanYs date of birth (month, Source of Income Amount of Income
$
If fded by a surviving, unmar ed spouse, what was the spouse's age at $ -
the time o( death?
TOTAL $
Have you filed for any other deductions? If Yes, what dedudions?
❑ Yes ❑ No
Have you filed for deduc6ons in any other county? If Yes, what county?
❑ Yes ❑ No
IIVJe certify under penalty of perjury that the above and foregoing infortnation is lrue and correct and that the applicant was a resi-
dent of Indiana and owner of lhe aforementioned property on March t, 20 _
S�re of a plicant Signature of authorized representative (by executed Powe� ofAttomey)
nddress of appiicant Address of authorized representative