Age_Dunn�=
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rr TOWNSHIP vena
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�• .� � 51ate Fmn 43708 (R7 / SOB)
Presmbed by tt�e Deparenen� of Laal Gwemment Finance
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�'mation contained in Ihis document is CONFIDENTIAL pursuant to IC G7.7-12-9 and IC Cr1.1-35-9.
INSTRUCTIONS: FILING A ES: '
To be filed in person or by mail with the County Auditor of the county where 1) Real proper��Qur�gj(h�QQ�onths before �une
the property is located. 11 0/ the ye'�l�e deduction is to be eNective.
2) Mo6ile ham sess der I.C.6-1-1-7;
See reverse side for additional instrucfion and qualifications. 6etween Ja� ��rch 31 of the year
the de���t�q�jf�tl�70ii
appllEan(the sole legal or equitable owner? If No, wn
Yes ❑No
name on record is diRerenl U an ihat oF appGcant, indipte b
ame of contract seller (appl�icant must have been buying on
ddress of contract seller
and ocwpied
exact share or inlerest?
one (1) yearJ
If owned vnih someone
indicate with whom
SPWISE,
property in question: � �
��Real properry ❑ Mobile home Q.G 6-14-n
number I �egal desc�ipdon ' Record number Page number
� -dU/- OdO. ��- %
. Assessed value ot ihe property as
❑Yes ❑No
Was the applicant 65 years oi age m more on December.31 oT ihe year
prior to the curtent year?
�Yes ❑No
-�
If @ed by a surviving, unmamed spouse, what was the spouse's age at
ihe Gme of death?
you filed fw any oiher
❑Yes ❑No
you filed fw deductions in any other
yea. (may na
�es t}ie combined annual adjusted gross inmme ot ihe appin
iividuals sharing uwnership exceed 825,000?
� ❑Yes
any
❑Yes ❑No I
I/We certify under penalry of perjury tha[ the above and foregoing info�=���n is true and correct and tha[ the applicant was a residenl
of Indiana and owner of the aforementloned property on March 1. 20 _ �
gnature W appliwnt SignaNre of authorized representative (by execufed Power ofAttomey)
,o � ,�w..�.-
idress ot applicant Address of authorized representative .
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