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3__ � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
t��� ! State Fortn 43708 (R4/ 10-07 )
Prescribed by the Depanmenl of Lowl GovemmeN Finance
�alion conlained in this document is CONFIDENTIAL pursuant to IC 6-t.t-12-9.
INSTRUCTIONS:
To be filed in person or 6y mail with the County Audito� of fhe county where
the property is located. �
See reverse side for adddional instruction and qualifications.
COUNTY TOWNSHIP YEAR
. [: File tvlark � �
FILING DATES: •
1) Real property: Dbrm�lh`� 'h1 ra�'�s before May
11 0/ the year the deducfion is to 6e effecfive.
2) Mobile hor ies assessefl uri�r 1.C.6-�1-1��;
between �4ar}�IS �d Ma�ch.3l�be year
the deductimr��lobeieffective.UDITOP,
Name of applicant nerorcontract 6vyerJ �
Is applicant ihe sol gal or equitable owner? If No, what is hisRier exacl share or interes[? If owned with someone other than spouse,
indicate with whom
es ❑ No
It name on rewrd is diRerent than ihat of applicant, indicate below
Name of contrad seller (applicant must have beon buying on contracf at least one (i) yearJ
Address o( conVad seller Is lhe property in queslion:
❑ Real property ❑ Mobile home (I.C. 61-7-n
Taring d' 'ct Key number / Legal description Rewrd number Page number
� 0: - / �1-3 -�
Is the property used and occupied prim 'ly (or Assessed Jalue of the property as of Marrh 1, currenl year (may not
hismer residence? exceed 869,000j
Yes O No
Was the applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ownership exceed $25,000?
1O Yes ❑ No ❑ Yes ❑ No
ApplicanYs date o(
$ 3�
If fJed by a surviving, unmarried spouse, what was the spouse's age at $
the time ot deathl
TOTAL $
Have you filed for any other deducGons? If Yes, what dedudions?
❑ Yes �'iJo
Have you filed for deducGons in any other county? If Yes, what wunty?
❑Yes ❑�
IlWe certify under penalty of perjury thal the above and foregoing information is true and correct and lhat the applicant was a resi-
dent of Indiana and owner of ihe aforemenlionad property on March 1, 20 _
Sign e f applicanl Signature of authorized representative (by executed Power o/Attomeyf
.
s of applicant Address of authorized representative
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