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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
SUte Fwm a3708 (R5 / 6-03)
Prescribed by Ne Dapartment of Local Govemrtrem Finance
Infortnation conWined in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
�'JCTIONS:
0 6e filed in person or by mail with the County Auditor of the county where
the property is located.
See reverse side /or additional instiuction and qualifications.
COUNTY TOWNSHIP YEAR
•z-File �Mark
� �
FILIN�T �: �
1) Real prop,eRy: Dunng t 1 months 6efore May
11 of the�ba} th`e t% is to be effective.
2) Mobile homes assessed under I.C.6-1-1-7;
6ehveen January 15�end March 31 o/the year
th�` deducfiorvis;to;be`eHecti've. -i �
�� GI3SON r°pUN? •< ;� .G;?n;_, 1
Name of applicant (owner or conhacf buyer)
(_'_ — �
Is aoolicant ihe sole leqal or equitable owneR If No, what is hisR�er exact share or interest? If owned wiN someone olher than spouse,
indicate with vrtrom
�es ❑ r,o
If name on record is different than Ihat of applicant, indicate below
Name oi conVact seller (applicant must have 6een buying on contract at least one (7) year)
Address ot conVact seller Is the prop rty in quesdon:
�al property ❑ Mobile home (I.C. 6-7-7-n
Taxin "strict � Key number / Legal descriplion Rewrd number Page number
�UY� Q=1=�o=-G-�C-�_o-�-��� �
�e property used and occupied primarity r Assessed value of Ne property as of March 1, wrtent year (may not
er residence? ezceed Sf44,000)
❑ Yes ❑ No p?
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the curtent year? individuals sharing ownership exceed 525,000?
❑ Yes ❑ No q.Yes ❑ No
AppiicanYs date of birth (
///��� /� s
If filed by a survi �ng, unmartied spouse, what was the spouse's age at /•�„ //_ i. _ _� J $ 5 5
the dme of death. l rC.C.4CA'L
TOTAL $ �
Have you filed for any oiher deductions? If Yes, what deductlons?
C�Yes ❑ No
Have you filed for deductions in any other county? � If Yes, what wunty?
❑ Yes Ud�lao
INJe certify under penalty of perjury that ihe above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20 _
Signature of pplicant Signature of authorized representative (by executed Power olAttomey)
e of appliwn� Q� � Address of authorized representative
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