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�S __ AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
= REQUESTING DEDUCTION FROM ASSESSED VALUATION
t��w ! State Fwm 43708 (R4 / 1P41 �
Prescribed by Ihe Depariment ol Local Govemmenl Finance
ITrtnalion contained in this document is CONFIDENTIAL pursuant to IC 6-1J-72-9.
INSTRUCTIONS:
To 6e filed in person or by mail wilh the County Auditor of the county where
the property is located.
See �everse side for additional inst�uction and qualifications.
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FILINGDATES:MAY 2 POOZ
1) Real erty: Duri tf 2 mo ,s fore May
11 0/ e ear th d '' t ective.
2)Mo , �yQ,dg!?. � �1-�-�;
between � anuary 15�and March 31 olthe year
the deduction is to be e/%ctive.
Name of applicant (owner r contract buyerJ
LQ. � , zAQE �-0�57�-,Po.�
Is applicant lhe sole gal or equitable owner? If No, what is his/her exact share or interest? If owned vrith someone olher than spouse,
� indicate with whom
Yes ❑ No
tl name on record is diRerent than ihal of applicant, indiwte below
Name of contracl seiler (applicant must have been buying on contract at leasf one (7) year)
Address of contrad seller Is the property in question:
Real pmperty ❑ Mobile home (I.C. 6-1-i-n
Taxing district Key number I Legal description Rewrd number Page number
Qu �.�Z�� C(O_%�3�3=00
Is the property used and occupied pnmarity for F�ssessed value of the property as o( March 1, wrrent year (may noi
hismer residence? exceed 569,000J
❑ Yes ❑ No
Was the appiicant 65 years of age or more on December 31 of the year Dces the combined annual adjusted gross inwme of ihe applicant and any
prior to the wnent year? individuals sharing ownership exceed 525,000?
❑ Yes ❑ No ❑ Yes ❑ No
Have you filed fw any other deductlons? If Yes, what deduclions?
❑ Yes ❑ No
Have you filed for deductions in any other county? If Yes, what county?
❑Yes ❑No
1/We ceRify under penalty of perjury that the above and foregoing information is true and correct and thal lhe applicant was a resi-
dent of Indiana and owner of the aforemenlionad property on March 1, 20 _ .
Signature of applicant Signature of authorized represenlative (by executed Power olAttomey)
Y ( ,�R/ '—
res pplipnt Address of authorized representative
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