Age_Leist^• t AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
't � ' REQUESTING DEDUCTION FROM ASSESSED VALUATION
'� � � State Fortn a3708 (R6 / G-0a) �
PrescAbed by Ihe Department ol Local Gwemment Financa
�rmaUon contained in this document is CONFIDENTIAL pursuant to IC 6-1.�-12-9 and IC 6-1.1-359.
INSTRUCTIONS:
To be �led in person or by mail with the County Auditor o! the counfy where
the propeRy is located.
See reverse side (or additional instruction and qualifications.
TOWNSHIP I YEAR
FILING DATES: q
1) Real property: Dun� g�h�'1 �rr�}}� before May
11 of the year the deduction is to be etfecfive.
2) Mobile homes a�"'essed u ¢� I.C.6-1-1J;
6ehveen ,(a 15 a��Stc�L?1 of the year
the deduchon � R%�b6'�eNgqti�D170R
Name ot applicant (owner oi contrac�r) � I
Is applicant the sole legal or equitable owne(.� If No, what is hislher exact share or interest? If owned with someone other than spouse,
� indicate with whom
t!J Yes ❑ No
I( name on record is diflerent than that of appliwnt, indicate below -
Name of contrad seller (applicant must have been buying on contract af least one (7) yearJ
Address of conUact seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6-1-1-7)
Taxing district Key number / Legal description Record number Page number
� � soto � � - iy -1 s -3 0 �F-�ov,sSD-oa�
Is the prope sed and occupied primarily for Asseued value of the property as of March 1, current year (may not
hisR�er residence? exceed S 744, 000J
es � No
Was the applicant 65 years of age or more on December 31 o year poes fhe wmbined annual adjusted gross income of the appiirant and any
priw to the curreni yearl individuals sharing ovmership exceed 525,000? ��
es ❑ No ❑ Yes ISYNo
Applicanl's
$
Have you filed for any other deductions7 If Yes, what deducUons?
� Yes ❑ No
Have you filed for deductlons in any other county? If Yes, what county7
❑ Yes ❑ No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that lhe applicant was a resident
of Indiana and owner oi the atorementioned property on March 1, 20 _
Signature of appliwnt Signature of authorized representative (by execufed Power otAttomey)
i
Ire s of appliwnt Address of authorized representalive
o� f p �