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a� '; AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
RE�UESTING DEDUCTION FROM ASSESSED VALUATION
Stare Portn 43708 (R / 9-96)
��4' Prescribed by ihe State Boartl ot Tax Commissioners
Information coniained in Ihis documen� is CONFIDENTIAL pursuant to IC 6-1.7-12-9.
INSTRUCTIONS FOR FILING:
To be filed in person or by mail with the County Auditor o/ the county where the property is loca-
ted during the 72 months be)ore May 71 0/ the year the deduction is to 6e effective.
Deductions for mobile homes noi assessed as real property must file benveen January 75 and
Ma�ch 37.
See reverse side !or additional instruction and quali)ications.
Name of applirani (owner or contr�ct buyerJ �
I5
or
� ❑ No
If name on record is diHerent than that of applican
Name of contraci seller (applicant must have beer
Address of contract seller
�i district /
�_
Is the property used and occupied primarny�
his/her residence?
i the applicant 65 years ot age or more on Dea
r lo Ihe Gurrent year? ' "
V`'�
rlicanYS date of birth (month, y, yearJ
ed by a surviving, unmarried spouse, what was
time oi death?
you filed for any oiher
you filed for deductions in any oiher
exaci
on conrracr ar ieast one
\
JAN 10 2000
��� / `. �DI
GIBSON 3uWTY AUD�IT�OrF '
u owned with someone other than spouse,
indicate wiih whom
I��-�- --==t= _�• I I
Assessed value of the property as of March 1, cuvent year (may no7
�� exceed $21.000)
L,"'1'es ❑ No � � �d ❑ Yes Oyta�
mber 37 of ihe year poes ihe combined annual adjusted gross income of the applicant and any
individuals sharing ownership exceed 520.000?
❑Yes �No
��
. ❑ Yes L,�'NO I
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 79
�awre of applicant � Signature of authorized representative (by execu(ed Power o1 Attomey)
d
`� �/ I � !O (O v
of authorized representative