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S__ ; AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
= REQUESTING DEDUCTION FROM ASSESSED VALUATION
� �N ! Slate Fortn 43708 (R4 / 16-01)
Prescribed by the Department of Local Govemmem Finance
In�rmalion contained in �his document is CONFIDENTIAL pursuant to IC 6-1.1-12-9. �
INSTRUCTIONS:
To be fled in person or by mail with the CountyAuditor of the county where
the p�opertyislocated. ('�_ �
�: �
G.Y�O
See �everse side tor additional inshuction and qualifications. �
COUNTY TOWNSHIP YEAR
� � �
Fil M rk
FEB � 1 �00�
FILING D ES: -
1) Real erty: ' th 2 mo �s fo2 May
�f o g,���6 � (�on��� � tfective.
2) Mobile omes assessed un er ..fi 1-1-7;
between January 15 and March 31 of the year
`a ...� �����..�., .� .� �� �..��.,.�.
Name of applicant (owner or contract buyer)
_ _ L .
Is applicant Uie wle I gal or equitab e own ? If No, vfiat hislher exact share or interest? If owned wiih someone other than spouse.
indicate with whom
5 ❑ No
If name on record is diflerent �han at oi applicant, indicate below
Name of contrect seller (applicant must have been buying on contract at least one (7) year)
Address of contrad seller Is fhe property in question:
eai property ❑ Mobile home (I.C. 61-1-n
Tabng districl Key number / Legal description Rewrd number Page number
- =ob-%��
Is the property used and occupied primari r Assessed value of the property as of March 1, current year (may nof
his/her residence? exceed $69,000J
❑ Yes ❑ No
Was the applipnt 65 years of age or more on December 31 of the year
Have you filed for any other deductions? If Yes, what deductions?
�es ❑ No
Have you filed for deduclions in any o�her county? it Yes, what wunty?
❑ Yes o
I/We certify under penalty of perjury that the above and foregoing information is irue and correct and that lhe applicant was a resi-
dent of Indiana and owner of the aforementionad property on March 1, 20 _
Signature of applicant Signature of authorized representative (by executed PowerofAttomeyJ
, �'tf� •
o( applipnt Address of authorized representative
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