Age_Brock4�, "•°.
4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
' ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
� ! State Fwm 43708 (R4 / 10-07 �
�• Presrnbed by ihe Department of Local Govemmem Finance
nafion contained in Ihis document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where
the property is located.
See reverse side foradditional instruction and qualifications.
af
Is applicant Ne sole tegal
name on
the
or cont2cf b r)
�� � �=��' �+�/ �-/1 y
❑ Yes ❑ No �
an that of applicant, indiwte below
contrad seller (applicant must have been buying on
of contrad seller
Key number /
f,�kes ❑ No
the applicant 65 years of age or more on December 31 e year
to the cuvent year?
es ❑ No
�plicanPS date of birth (mon[h, day, yearJ
��-
filed by a surviving, unmarried spouse, what was
e time of death7
you filed for any
you filed for deduc6ons in any other county?
age at
❑Yes ❑No
❑ Yes ❑ No
exact share or
one
COUNTY TOWNSHIP YEAR
,,^;'�
File�rk
FILING DATES: AP� 1(j Z003
1) Real propeity: During the 12 months before May
11 of th� year the deduction�is to be e/fective.
2) Mobile�omes-a ess ssed pderl.C:6-1�-7;
� ... _ _ � l� —�-�.., s
between Januaty�l5�and Marcb 3� ofihe year
w� � vh I
the deduction is to be e/%ctive.
with someone other lhan spouse,
with whom
Isthe property
❑ Real property ❑ Mobile home (I.G 6-1-1-7)
Rewrd number Page number
the property as of March 1, wrrent year
Uoes the combinetl annual atljusfed gross incor
individuals sharing ovmership exceed S25,000?
$
INJe certiy under penaity of perjury that the above and foregoing information is irue and correct and that the applicant was a resi-
dent of Indiana and owner of lhe aforementioned property on March 1, 20 _
ot applicant