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! AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
ti � State Form 43708 (R5/ 6-03)
�«.
Presuibed by Ne Depamnent of Locel Govemment Fnance
Infortnatlon contained in this documenl is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
COUNTY TOWNSHIP YEAR
File Maric
�RUCTIONS: FILIN DAIESi] �
i
To be filed in person or by mail with the Counry Auditor of the county where 1).�al pri�pe�;.Du i�q_the 2 onths belore May
ihe property is located. 11 0( the year the deducfion is to be etfective.
2) MobileJpi�fnes a�s�� under I.C.6-1-1-7;
See reverse side (or additional instruction and qualifications. between January�5 and March 31 of the year
�he deductioa is to�be eflective..
applic�hCNe sole legal or equitable owne(� �- - If ITo, what
V
L Yes ❑ No
name on record is difterent than that of applicant, indicate bel�
contraCt 9eller IaDDllcant must
4ddress of conVa� seller
iaxi distri �
property used and occupied primarii r
.er residence?
Was the applicant 65 years of age or more on Dea
pnor ro lhe current year?
ApplicanYS date of birth (rtronth, day, year)
was
Ihe Gme of deaih?
Have you filed for any other deducGons?
Have you filed for deductions in any other county?
on
exact share or interest?
number / Legal description
:5 ❑ No
31 of the year
❑ Yes
�
If owned wiN someone other than sDOUSe,
indicate with whom
Is the property in question:
property ❑ Mobile home (I.C. 6-1-7-n
number Paae number
as of March 1, current year (may not
combined ann� fal adjusted gross income of the applicant and any
s sharing ownership exceed 525,000?
❑ Yes ❑ No
af Ineome Amount of Ineome
_ i _� � �
age at $
TOTAL $ �
If Yes, what
what count�
❑ Yes �No I
IIWe 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 _
C,
�� y I-.�.� �f"