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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, co r m+s P v
REQUESTING DEDUCTION FROM ASSESSED VALUATION
: ! State Fpm 43708 (R7 / SUB)
.. I� PresmLeO by Ihe Deparhnrnl of Lod Govemment Fuiance '
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,. �.mation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-72-9 and IC 61.1-359.
INSTRUCTIONS:
To be (led in person or by mail with the County Auditor of the county where
the propeRy is located.
See reverse side for additional instrucfion and qualifications.
�
Is ayptinnt ihe 561e legal or
❑Yes ❑No
name on record is difierent than Nal of appiipn
must have been
r.r�rca�
the applicant 65 years of age or more o�
to ihe artent yeaR
App&anYs date of birih (monM, day, yea
�
Ii filed by a surviving, unmartied spouse,
fhe Ume of death?
IIti9
you
arry
i�-�
what is hisTher exacl share w interes
on conUad at leasf one (7) year)
FILING DATES: � �`� � �
1) Real property: �p0'8�1��1NdriPFi9��a��une
11 of the year the deduction is to be effective.
2) Mo6ile homes assessed under I.C.6-1-1-7;
6etween January 15 and March 31 of the year
the deduction is to be eflective.
y number I Legal description
6-i7-ol-�f��F-oa°, 3�3
.�Yes ❑No
em�be/c3l of the year
,[y1'es ❑No
was the spouse's age
❑Yes ❑No
any other counq!�
If owned with someone other Nan spouse,
indicate with whom
Is the property in question: �
�Real property � Mobile home (LC. E1-1-7)
Record number Page number
:A value of the property as
5144.000)
the combine�
luals sharing
1, wrtent year (may nof
justed gross income of the applipnt and any
exceed E25.000?
$
❑Yes ❑NO (
I/We certify under penalty of perjury that the above and foregoing info�**�����n is true and correct and that the applicanl was a resident
of Indiana and owner of ihe aforementloned property on March 1, 20 _ ,
gnaWre of ap�cant , SignaWre ot authorized representatrve (by erecufed Power oiAttomey)
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3 O� `i�. �
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Address of authorized