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° � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP venR
°� " REQUESTING DEDUCTION FROM ASSESSED VALUATION
y �� SUte Fortn a3708 (R6 / 4-Oa) '
•• Prescribed by che Department ol Local Govemment Finance
File Mark
rmation contained in this document is CONFIDENTIAL pursuant to IC 6-7.�-12-9 and IC 6-1.1359. �
INSTRUCTIONS: FILING DATES:
To 6e �led in person or 6y mail with the County Auditor of the county where 1J Real pioperty: Du�ng the 12 months 6efore May
the property is located. 17 777��� e d i be ef(ective.
2) M�e �e ,asse cap u de C.6-1-1J;
See �everse side for addilional instruction and qualifications. be�ee 1 31 of ihe year
the deduction is to be effective.
ame of applicant (owne� oi onfr buyer)
applicant the sole legal or equltabie owne��
�❑Yes l
name on record is different than thal of api
seller
�
share orinterest?
on conhacf a( least one (7) year)
:?-Jv -I q - 3 / - 30/ - 000, �8 y -,
Key number / Legai description
�� a / � -bo d
Was Ne applicant 65 years of age or more on
prior to the curtent year?
AppliwnCs date of
Ii filed by a surrivi,
tha tlme of death?
Have you filed for
Have you filed for
- ��
married spouse, what was
any other
any
Yes
� Yes
❑ No
the year
O No
age at
�la� ,�
spouse,
property in question:
� Real property ❑ Mobile home (I.C. 6-1-7-7)
Record number Page number
�y-�o I I
ed value of the property as of March 7, cuvent year (may nof
$144,000J
.e combined annual adjusted gross income of the applicant and any
als sharing ovmership exceed 525,0007
❑ Yes ❑ No
Source of Ineome Amount of Ineome
�
s
TOTAL $
❑ Yes �No �
IlWe certiry under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20 _
of applicant
D ii/. An A . �
5/
of authorized representative
oJAtlomeyJ