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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP r�
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�+ ! State Form 43708 (R7 / 5-06)
PresrnLeA Dy the Departnient of Locai Gwemment Finance
In�fortnation contained in this dowment is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-1.135-9. e a
INSTRUCTIONS: FILING DATES: FEB 1 5 2OOE
To be filed in person or by mail with the Counry Auditor of the county where 1) Real property: During the 12 months before June
the property is located. 11 of the year��,du is to 6e eHective.
2) Mobile homes ass�;dsed u r LC.6-1-7J;
See reverse side for additional instruction and qualifications. betwe�ii���QB�fib ICOgIdf(,Y�t of the year
the deduction is to 6e effective.
Name of appiicanl (�
Is applicant Ne sole
N rame on record is
Name ot conVaci sf
Address of contrad
❑Yes ❑No
ihan that oI applican'
, - 4 36- yD,
mperty used and oowpied
residence?
No, what is hisRier exact share a
must have been 6uying on contract
! �egal desaiption
�Yes ❑No
ihe applicant 65 years of age or rtrore on Decembec3l� of the year
to the currenl yearT .
date oi b'uth
If filed by a surviving, unmarried spouse.
the Gme of death?
Have you filed for any other deductions?
❑Yes ❑No
was ihe spouse's age at
❑Yes ❑No
you filed for deducdons in any other count�
I wiN someone other Nan spouse,
with whom
Is the propeAy in questlon: �
❑ Real property ❑ Mobile home (I.C. fr1-1-n
Record number Page number
of ihe propeAy as
$
oY� ❑No �
I/We certify under penalty of perjury that the above and foregoing info�����n is true and correct and thai ihe applicant was a resideni
of Indiana and owner of the aforementioned property on March 1, 20 _
Signalure of ap ' t Signalure of authwized representative (by executed Power ofAttomey)
_��r��'—� �� iQi.��ra'�Z��
/ . " ��
ot auiho�ized