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s AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+TV TOWNSHIP veaR
REQUESTING DEDUCTION FROM ASSESSED VALUATION -
S � State Fwm 43708 (RS / 6-03)
a•
Prescribed by the Departmam of Loral Govemrtrent Finance
File Mark
Infortnation contained in this document is CONFIDENTIAL pursuant to IC �2� ���
�RUCTIONS: F L/ G ATES:
To be filed in person or by mail with the County Auditor of the coun where 1) Real property: During the 12 months before May
the property is Ixated. � �T 1 7 2�03�� o/the year the deducfion is to be effective.
� 2) Mobile homes assessed under I.C.6-1-1-7;
See reverse side for additional instniction and qualificalions. � � /� belween January 15 and March 37 0/ the year
�. yl the deduction is to be eHecfive.
aoolicant the sole legal or equitatlfe owneR
es ❑ No
name on record is difFerent than Ihat of applican
ame of conVact seller (applicant must have 6eei
�dress ot contract seller
'n distn� ,
�e property used and occupied primari r
er residence?
whatis hisRier exactshare orinterest?
on contract at �east one
number / Legal
I with someone oth than spouse,
with whom
Is the property in question:
eal property ❑ Mobile home (I.C. 6-f-1-n
number Page number
� ) {' /�� V
r =-V—v— _•' —�1
Assessed value ot Ne property as of March 1, wrrent year (may not
exceed 3744,000)
es ❑ No
Was Ne appllcant 65 years ot a9e or more on Uecemoer �t ot tne year
prior to the curtent year? �
es ❑ No
Applicant'
you filetl for any
you filed for deductlons in any
� Yes
❑ No
Does the combined annual adjusted gross income ot the applicant and any
ndividuals sharing ownership exceed 525,000?
❑ Yes ❑ No
�
If Yes, what deducUOns?
IM/e certify under penalty of perjury that the above and foregoing information is true and correcl and that the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20 _
of authorized representative
of authorized