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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED
VALUATION State Form 43708 (1-90) Prescribed by the
State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the County where the
property is located during the 12 months before May 11 of the year the deduction
is to be effective. Deductions for mobile homes not assessed as real property
mustfile between January 15 and March 31. See reverse for additional instructions
and qualifications.
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AUDITOR
Applicant (Owner or contrac r
Is applicant the sole legal or If no, what is his/her exact share or If own with someone other than
equitable owner? � yes O no interest? spouse, indicate with whom.
If name on record ' iff rent than that of appl t, indicate belo .
Name of contract seller (Applicant must have een buying on co act at least one (1) ye )
Address of contract seller •
ri Pi c Key u er/Le al Descri tion Record No.
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Is the real pro e y used a occupied primarily Assessed value of the property as of March 1, current
for his/her resi nce? yes O no year (may not exceed $19,000).
Was the pplicant 65 years of age or more on ApplicanYs date of birth _ ��
Dec er 31 of the year prior to the current year? �
yes O no If filed by a surviving, unmarried spouse, what was the �
spouse's age at the time of death? j:
Does the combined annual adjusted gross Sourc of ' come Amount of income
income of the applicant and any individuals
sharing ownership exceed $15,000?
� yes O no
Total.
Have you filed for any other deductions? If yes, what deductions?
Have you filed for any deductions in any other county? If yes, what county?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-.
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
�;qnature Authorized Representative (by executed Power of Attorney)
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Addr ss of plicant Address of RepresentatiJe
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