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? AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP vEO,rt
'� � ' REQUESTING DEDUCTION FROM ASSESSED VALUATION
�� ,��� � State Form 43708 (R6 / 4-Oa) �
�
Prescnhed by �he Department ot Local Govemment Finance �j' �� �
� i ��
�nalion wnlained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-3&9. ��'� �1:.,.,� ; ile �k
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county where
the property is located.
See reverse side !or additional instruction and qualifications.
buyerJ
C
owneR If No, w at is
�s ❑ No I
If name on record is diRerent than that of applicant, indicate below
of d�fjtract seller
the applirant 65 years of age or more on
to the cunent year?
etl by a surnvi
fime of death?
on
one
or
FILINGDAT�wSl e� Z005
1) Real property: Dunng the 12 months 6efore May
11 of the yea � e�deduction is to be eNective.
�) Mobile homes assessed under 1.C.6-1-1-7;
�ietx�eenUeOp�ry{����aq,d March 31 o(the year
the deducfion is fo e'�ctive.
with someone other than spouse,
with whom
Is the property in question:
Real property ❑ Mobile home (I.C. 6-7-1-n
Key number / Legal description Record number Page number
n� � -Do3 �9-0
Asseued value of the property as of March 1, current year (may not
exceed S 744, 000)
❑ Yes ❑ No
mber 31 ot ihe year poes the wmbined annual adjusted gross income of lhe applicant and any
individuals sharing ovmership exceed 525,0001
�Yes ❑ No
fh, day, year)
-/ ��
ed spouse, what was the spouse's age a
you filed (or any other deductions?
❑ No
Have you filed for deductions in any other county?
If Yes, what
❑ Yes C
of I me A oun of
$
TOTAL $ `
❑ Yes �(JJo �
IIWe certify under penalty of perjury that the above and foregoing informalion is true and correct and that the applicant was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20 _
(
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o�/�L,4y n G/�Y
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of authorized representative