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,F AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
° Stete Fwm 43708 (RS / 6-03)
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Prescribed by the Dapartment of Lopl Govemment Finance
InfortnaGon conWined in this document is CONFIDENTIAL pursuant to IC 6�1.1-72-9.
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auddor ot the county where
the property is located.
See reverse side /or additional instruction and qualificatlons.
COUNTY TOWNSHIP YEAR
File Mark
FILING DATES:
1) Real property: During the 12 months before May
11 0/ fhe year the deduction is to be eHective.
2) Mo6ile homes assessed under I.C.6-1-1-7;
between January 15 and March 31 of the year
the deduction is to be effective.
Name of applicant (owner or contract buyer)
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Is aOPlicant the sole legal or equitable owneR If No, what is hisRier e cl share or interesi? If owned with eon .other-ihenfspou's
indicate with whom
es ❑No OCT 17 2003
If name on record is difierent Ihan that of appliwnt, indinte below /�
n�/i��_ ..._.- _—I
Name of conVact seller (applicant must have baen buying on contract at least one (1 J}reaiJ ----"" '" ``• '"""'" ''
Address of conVact seller Is the property in question:
� eal property ❑ Mobile home (I.C. 6-7-7-n
�'�ng sVict Key number I Legal description Record number Page number
���, � . - - - - �U�
Is the property used and occupied primarily for Assessed value of the property as of March 7, curtent year (may nof
hislher residence? exceed $144,000)
es ❑ No
Was Ne applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of tha applicant and any
prior to Ihe current year? individuals sharing ovmership ezceed 525,000? �
es ❑ No ❑ Yes fi}'f�o
AppliranYs
TOTAL 5 �
Have you filed for any other deducUons? If Yes, what deductlons?
❑ Yes ❑ No
Have you filed for deduMions in any oiher county? If Yes, what wunt�!�
❑Yes ❑No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of auihorized representative (by ezecuted PowerofAttomey)
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dress of appliw�7nt �� ,/ Address of auNOrized rep2sentative
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