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dj rt•,OS AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
-d REQUESTING DEDUCTION FROM ASSESSED VALUATION
�. State Porm 43708 (R / 9�96)
"�' Prescribed bY Ihe State Board of T� Commissioners
Information contained in ihis document is CONFIDENTIAL pursuant ro IC 6-1.1-72-9.
INSTRUCTIONS FOR FILING:
To be filed in person or by mail with the County Auditor o/ the counry where the property is loca-
ted during the 72 months beloie May i l ol the year the deduction is to be effective.
COUNTY TOWNSFiIP YEAR
�,�� Frple`-DAer `
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APR "I 0 2000
Deductions !or mobile homes not assessed as �eal property must file benveen January 75 and
Ma�ch 37. (///```
See reverse side !or additional instruction and qualifications. .1��-� 1, �'�
. i; -,� ��:_� _�L!;?. .._�..—.... .
Name of � ni (owner or contract buy
Is applicant e sole Iegal or e uita le ner. If No, what is his/her exact share of interest? If owned with someone other ihan spouse.
indicate with whom
❑ Yes ❑ No
If name on record is ditterent ihan that of applicant, indirate below
Name of con act seller (applicant must have been buying on contract at least one (1) year)
�
Address f contract seller
in districi Key number / Legal description Record number Page number
I (�/C�-bb 735�b
Is the property used and occupied pri Ay tor Assessed value of the property as of March 7, current year (may not
hisfier residence? � � exceed 521,000) /,,
d�/Es ❑ No lY �� ❑ Yes � No
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 wrrent year? individuals sharing ownership exceed 520.000?
❑ Yes ❑ No
Applicant's date
Have you filed tor any other deduciions? If Yes, what deductions? .
❑ Yes C� �
Have you tiled for deduciions in any other couniy? If Yes. whai counry?
❑ Yes
L� I
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 _ �
Signature of applicant SignaWre of authorized represemative (by executed Power o/AnomeyJ
�`'�—C'J�. .
hd ress of applicant Address of amhorized representative
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