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__ � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
� ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
t � State Fwm 43708 (R4 / 70-01)
�•� Presaibed by lhe Department ot Local Govemment Finance
mafion contained in Ihis dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To be (led in person or by mail with the County Auditor of the county where
the property is located.
See reverse side !or additional instrucfion and qualifications.
Name of ppli� t(owner or contracf buye
y
Is applican the• ole legal o q' ble owner? I , what is t
Yes ❑ No
If name on rewrd is dirterent an thal oi applicant, indirate below
Name of contraq se r(applicant must have been buying on contr
�as tl�e applicant 65 years of age or more on
ior to the curtent year?
pplicanPs date
fded by a surviving, unmarried spouse, what
e 6me of death?
ave you filed for any olher deducUons?
you filed (or deducGons in any
Keynumberl
❑ No
he year
Yes ❑ No
was fhe spouse's age at
■ .
exad
one
or
COUNTY � TOWNSHIP � YEAR
F 1) Real�property.BD � g th�Y� montYs 6efore May
11 e year the de�tion is to 6e eHective.
2) M- il ho se d un I.C� 1-1-7;
e�, , n �,�ah`dYvf� �1 oI the year
the �e�uciionisYo be eifectiv"e: �
� with someone other than spouse,
with whom
Is the property
❑ Real property ❑ Mobile home (I.C. 61-1-n
Rewrd number Page number
ihe property as of March 1, wvent year
Dces the combined annual adjusfed gross income of the applicant and any
individuals sharing ownership exceed 525,000?
If Yes, what wunty?
❑ Yes ❑ No
of Income Amount of Incoi
$
$
TOTAL $
�s? n ^
� 7�--'�-� / , 1 �
❑ Yes I�Jo �
/ '
I/We cerlify under penalry of perjury thal the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of lhe aforementioned property on March 1, 20 _
mNre of a licant Signature of authorized represenlative (6y executed Power ofAttomey)
;J_-�-��ii 1���-�
of authorized representative
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