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4 ': AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
� REQUESTING DEDUCTION FROM ASSESSED VALUATION
S �� Stata Fortn 43708 (R6 / 4-04)
Prescribed by the Department of Local Gavemment Finance
InTortnatlon contained in this document is CONFIDENTIAL pursuant to IC 6-1.7-72-9 and IC 6-1.1359.
INSTRUCTIONS:
To be filed in person o� by mail with the County Auditor of the county where
the property is located.
See reverse side (or addifional rnstruction and qualifications.
COUN7Y TOWNSHIP YEAR
FILING DATES: APR 2 1 ZOOS
1) Rea/ property: During the 12 months be(ore May
11 0/ the year th�� ctio�, be e/fective.
2J Mobile homes a�ses� Ln .Ei-1-7;
6efween ,AIS@�fdiG9qpUfp/p�h'PfF�he year
the deducfion is to be effective.
Name of applicant (owner or conhac uye�) �
Is applicant the sol legal or equitable ovmeR If No, what is hislher exact share or inierest? If owned with someone other fhan spouse,
' indicate with whom -
Q Yes � No
If name on record is diflerent than that of appliwnt, indicate below
Name of conVact seller (applicant must have been buying on contract at least one (i) year)
Address of contract seller Is the property in question:
e I property ❑ Mobiie home (LG 6-14-�
T'ng district Key number / legal descripUon ecord number Page number
•� - 6 - ,
Is ihe property used and occupie primarity for Assessed value of the property as of March 1, current year (may not
hisRier residence? exceed 3744,000J
❑ r,o � O �
Was the applicant 65 years of age or more on Dece ber 31 of the year poes the combined annual adjusted gross income ot lhe appiicant and any
prior to the current year? individuals sharing ownership exceed $25,000?
❑ No ❑ Yes o
AppliranPs date of birth (
$
the dme of death?
TOTAL $
Have you filed (or any olher deductions? If Yes, what deducdons? �
❑ Yes o
Have you filed for deductions in any other county? I( Yes, what county?
❑ Yes
I/We certify under penalty of perjury that the above and foregoing information is true and correct and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature ot authorized representative (by executed Powe� olAttomey)
s of applicant Address of authorized represeniative �