Age_McDonald'` �_• 4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
` ,��� � State Form 43708 (R6 / 4-04) '
Prescnbed by Ihe Department of Local Govemment Finance
�rtna6on wntained in this documeni is CONFIDENTIAL pursuant to IC 6-1.7-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
To 6e �led in person or by mail with the CountyAuditor of the county where
the property is located.
See reverse side for additional inst�ucfion and qualifications.
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` ' �.
FEB 2 3F'i�e.�n�n�rk
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FILING DATES:
1J Real property During the.l2:months before May
)11 ofthe.yQ�,{h�q fled4c�io��'s�� eNective.
2 Mobil�7�e�a�s�e'�ed��u'er .c.s-�-�a;
between January 15 and March 31 of the year
the deduction is to be eflective.
Name of applic (o ner or contract buyer I
�� � ; �c ���
Is applicant so e legal or equitable owner? exad share or interest? If owned wiN someone other than spouse,
' indicate with whom
Yes � No
If name on record is diHerent than thal oi applicant, indiwte below
Name of wntrect selier (applicanf must have 6een buying on contract at least one (7) yearJ
Address of contrad seiler Is the property in ques6on:
a�-aa-o�-�zoi- 000,a98-
� Real property ❑ Mobile home (I.C. 6-1-7-7)
Ta�dng district y number / Legal description Rewrd number Page number
� Di3 - �oa 4 � -�
Is lhe property used and occupied pnmarity for Assessed value of fhe property as of March 1, current year (may not
hisfier residence? exeeed $144,000J
❑ Yes ❑ No
Was Ihe appiicant 65 years of age or more on December 3� of the year poes the combined annual adjusted 9ross income of the appiicant and any
prior to the wrrent year? individuals sharing ovmership exceed 525,0007
OYes ❑No OYes ❑No
ApplicanPs
- � $
I( fJed by a surviving, unmartied use, what was the spouse's age at $
the tlme of deaN? �
TOTAL $ •
Have you filed for any other deductions? II Yes, what deductions? '
❑ Yes ❑ No
Have you filed for deductions in any other wunty? If Yes, what county?
❑ Yes O No
IMIe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a residenl I
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant SignaNre of authorized representative (by execufed Power olAttomey)
1%�, /�(c �tS�.d�
ress of applicant ��� IAddress of authorized representative I
I.��3�U ��nles� $�ATE G�cao�
I H�u�Sta�t rn/ �7l,s9