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� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S � Stata Form 43708 (RS / 6-03)
N�
� Prescribed by Ne Department of Loral Govemment Finance
Information conWined in this document is CONFIDENTIAL pursuant to IC 61.1-12-9.
COUNTY TOWNSHIP YEAR
� Fil�rk
�RUCTIONS: FILING DATES: O C T O 2 2003
To be filed in person or 6y mail with the County Auditor of the county where 1) Real property: During the 12 months before May
the property is located. 11 of t ear fhe de�uct � is [o be eff¢�tive.
2) Mobi &a S se�7i/nder l. .6-'/y7-7;
See reverse side for additional insfruction and quali�cations. between��i&�1hty�eqd� �the year
the deduction is to be effective.
Name of applicant (owner or contract
❑ No
name on
Name of wnVaIX seller (applicant must M1ave 6een
seller
property use
r residence?
Wllat IS IIIS/I10f exaGI511a2 of
e below
on contrect at least one !71 ve
Yes ❑ No
Was the applicant 65 years of age or more on December 31 ot ihe year
pdor to lhe current year?
�Yes ❑ No
ApplicanPS date of birth (month, day, yearJ _
�
s age at
the Gme of death? �
you filetl for any
you filed for deducUons in any
❑ No
❑ Yes ❑ No
It OWnetl WIUI SORIBOI1e olllef Nafl SPOU50,
indicate wiN whom
Is the property in questlan:
❑ Real properry ❑ Mobile home (I.C. 6-1-1-�
Record number Page number
ihe pmperty as of March 1, current year
riT.A
Does the combined annuat adjusted gross income of the applicant and any
individuals sharing ownership exceed $25,000?
Source oi Income
Yes,whatdeducUons?
I( Yes, what count�!�
TOTAL I S
❑ Yes ❑ No
Amount of Ineome
IIWe certify under penalty of perjury that the above and foregoing information is true and correct and that Ihe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
o(AttomeyJ
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