Age_Miller (3)R.�
4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrv TOWNSHIP vea,R
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
��w � Slate Fortn 43708 (Rd / 10-01 � ���,-----���}} i
� Prescribed Dy Ihe Depanment oF Local Govemment Finance �.. � ��
malion wntained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
�„/ ` ` ark
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.
Name of applicant (oAlhr or wnGacf
Is applicanl the sofe legal or
❑ Yes ❑ No �
name on record is dirterent Uian that o( appiicanl, indicate below
ame o( conlrad seller (applicanf must have beon buying on contract at
district
❑Yes �No
s the applicant 65 years of age or more on December 31 of the year
v to lhe curtent year?
❑ Yes ❑ No
ilicant's
ed by a surviving, unmartied spouse, what was the spouse's a9e at
fime o( death?
you filed for any other deduc6ons?
you
❑ Yes ❑ No
any other county?
exact share or interest?
FILING �S� � ?003
1 Real propeRy Dunng the 12 rrtonths belore May
�11 0/ the year t��deduction is�to be e/%ctive.
/2)�Mobile'hoMes;assass"e�rirtder I.C.6-1-1-7,-
'� 3'e3idderidarivary 15 and Maioh 31 of the year
the deduction is fo 6e eKective.
If owned with someone other than spouse,
indicate with whom
Is the property in question:
� Real property ❑ Mobile home (I.C. G1-7-�
Record number Page number
Assessea�value ot [he property as of March 1, cUrrent year (may not
exceed 569,000J
Does ihe wmbined annual adjusted gross income o( the applicant and any
individuals sharing ovmership exceed $25,000?
❑ Yes ❑ No
$
❑ Yes ❑ No 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-
denl of Indiana and owner of the aforementioned property on March 1, 20 _
ature of applirani � Signature of authorized representative (by executed Power o)AttomeyJ
�