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1�' AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTr TOWNSHIP venR
REQUESTING DEDUCTION FROM ASSESSED VALUATION
•° uo � State Fortn 43708 (RS / 6-03) �
P�escnbed by Ne Departrnent of Loral Govemrtrent Fnance �'1 U� 'j � �� ��
j"'� �S �a File Marli'
��rnation conWined in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9. � },i h--� ��-`
RUCTIONS:
To be filed in person or by mail with the County Auditor of the county where
the property is located.
See reverse side /or additional instiuction and qualifications.
Name of appliwnt
or
ir�
�Yes ❑ No I
name on record is difrerent tha, that of applicant, indicate below
Name of conVact
residence?
(appliwnt must have been buying on
� �
❑Yes ❑No
the applicant 65 years of age or mwe on December 31 ot the year
to the wrrent year?
etl by a
Gme of death9
�e you fiied for any other deductions?
❑Yes ❑No
was the spouse's age
❑ Yes
you filed for deductions in any oNet county?
❑ Yes
exact
one
FILING DATESJ N 1 6 Z�O4
1) Real property: Dunng fhe 12 months.before May
11 of the year the'deduction is (0 6e�eBective.
2) Mobile homes assessed under7:C 6-1-1-7;
t-u^--- �... , r,,.,
6etwsemJanuary}15 and.INarch 31 0/ the year
the deduction is to 6e eNective.
i someone other
whom
_ �IS the pmperty in question:
❑ Real property ❑ Mobile home (I.C. 6-7-1-n
Record number Paoe number
Assessed value of the pmperty as
ezceed 8144,000J
1, current year (may not
Does the combined annual adjusted gross income of the applicant and any
individuals sharing ownership exceed 525,000?
what
❑ Yes ❑ No
Amount of Incoi
5
$
TOTAL $ �
I/We certify under penalty of perjury that the above and foregoing information is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ �
Signature of ap0liwnt Signature of authorized representaUve (by executed Power o7AttomeyJ
. �
of applic nt
/0 9 1'�• ,3'�O ST.
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