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� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S�M � Stata Fatm 43708 (R5 / 603)
" Piescribed by the Department of Local Govemment Finance
Intormation contained in this document is CONFIDEN7IAL pursuant to IC 61.1-12-9.
�TRUCTIONS:
To be filed in person or by mail with the CountyAuditor o/ the counry where
the property is located.
See 2verse side for additional instruction and qualifications.
COUNTY TOWNSHIP � YEAR
File Mark
FILING DATES:
1) Real property: Dunng the 12 months be(ore May
11 o/ the year the deduction is to 6e et(ectrve.
2J Mobile Aomes assessed under I.C.6-1-1-7;
6ehveen Jano ry 15 and �March 31�o%fhe year
the deduction� to �eRecfli �� (� �]
It�
Nameo(applicant(owne�orc nt2ctbuye�J JUN J 2��4
� � r' `� 1 /.� . /%
Is applicant the sole legal or equitable owner? If No, what is hisRier fshare w interest? If owned wiN someone other ttian spou3e, //
� intlicate wiUi�wfiom'�"'!/! :J��! J'
�` CLSGC: COUt T r AL'"�;TC', :
es ❑ No
If name on record is diRerent Nan that ot applicant, indinte below
Name of contraCt sel r(a plicant must have been buying on cont2ct at least one (1J year)
w
Address of conVact sel r Is the property in questlon:
Real property ❑ Mobile home (I.C. 6-7-1-n
Ta�cing dist �ct � Key number I Leqal desuiption Record number Page number
� - _ =3=-�o3n� --co
property used and occupied primarily for Assessed value ot the property as of March 7, curtent year (may nof
er residence? exceed 8144,000)
Yes ❑ No
Was the applicant 65 years of age or more on December 3'I of the year poes the combined annual adjusted gross income of the applicant and any
prior to the curtent year? individuals sharing ownership exceed 525,000?
es ❑ No ❑ Yes ❑ No
Applicant's date of birth (month, day, yearJ /_ � �
$ �
Have you filed for any other deductions? If Yes, what deducUons?
❑ Yes No
Have you filed for deductions in any other county? If Yes, what county?
❑ Yes a
I/VJe certify 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 1, 20 _ .
Si. gnat �e of appli� Signature of autho�zed represeniative (by executed Power ofAttomey)
(V Q�
Address of applicant Address of authorized representative
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