Age_Lanen•n ' AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE� CoUNTY TOWNSHIP YEAR
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i � REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' State Fortn 43708 (R6 / 4-Oa)
Prescribed by ihe Department of Local Govemment Finance
File Mark
ation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1359. �
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INSTRUCTIONS: FiNNG C��A� 9 y
To 6e filed in person or by mail with the County Auditor oI the county whe�e ' -'1� Rea�pro e: Dunn the 12 months 6e(ore Ma
the property is located. 11 of the�ey t�e�ction is to be elfective.
2)Mobi�ti�frri�s ssedunderl.C.6-1-1-7;
See reverse side !o� additional instruction and quali�cations. between January 15 and March 31 0l the year
the dedaeG� �d�e/fective.
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Name of applicant (owner or cont ct b yerJ � G�BgpN COU �
Is applicant the sole legal or equitable owner? If No, what i hislher exact share or interesf? If owned with someone other than spouse,
indicate wifh whom
Yes �lo
If name on record is diRerent than that of applicant, indicate below
Name of contract seller (a /icant must have been buying on contract at least one (i) yearJ �
w
Address of contrad II r Is the property in question:
. ❑ Real property ❑ Mobile home (I.C. 6-1-1-n
I Ta�dng dis t Key number / Legal description Record number Page number
Q,`��� Q / � -b0� 33 -oa
e e properry used and occupied primarily f r Assessed value of the property as of March 1, curtent year (may not
hisR�er residence? � exceed 5744,000J
❑ Yes ❑ No
Was the applicant 65 years ot age or more on December 31 of the year
$
Have you filed (or any other deductions? If Yes, what deductlons?
❑ Yes
Have you filed tor deductions in any other counry? If Yes, what county?
❑ Yes
IIWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20
Signature of appiicani Signature o( authoriied representative (by executed Power o7Attomey)
I
'�ess of appliwnt P,ddress of authorized representa6ve
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