Age_Headfr�,_rt•n !; AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE�
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
S,��� � State Fortn 43708 (R6 / 4-Oa) �
Presuibed by ihe Depariment of Lowl Govemment Fnance
�rtna6on wntained in this document is CONFIDENTIAL pursuant to IC 6-1.7-12•9 and IC 6-1.1-359.
COUNTY TOWNSHIP YEAR
�ile rk
INSTRUCTIONS: FILING DATES:�UN � S ZOO6
To 6e filed in person or by mail with the County Auditor o! the co�nty where 1) Real property: Dunng the 12 months before May
the propeRy is located. if 1 h
See reverse side to� additional instruction and qualifications.
o( applicant (owner or confract
or
�Yes ❑ No �
name on record is diBerent than that of applicant, indicate below
wntrect
"L
Address of conVact seller
hismer residence?
� ��dQ
is/her exact share or interes
on contrect atleast one ryJ year)
o t e year'he dedochon is to be eNechve.
2) Mobile homes assesse`ar+t3r�'tlerl.C.6-1-1-7;
behv��u�5��4d�r��1 ofthe year
the deduction is to be effective.
I with someone other than spouse,
wifh whom
Is the property in question:
' I� I"�. a3�,lA� ❑ Real property ❑ Mobile home (I.C. 6-14-7)
nber I Legal description Record number TPage number
O{�fes ❑ No
the applicant 65 years of age or more on December 31 ot the year
to the cunent year?
L�Yes O No
�-�
/ a surviving, unmartied spouse, what was
of death?
you filed (or any other
you filed for deducGons in any other
❑ Yes
❑ Yes
age at
�d � �
�d value of the property as of March 1, current year (may not
5744,000J
$
I/We certify under penalty of perjury that the above and foregoing informalion is true and correct and ihat the applicant was a resident
of Indiana and owner of the aforementioned propeRy on March 7, 20 _
3natu/e f applicant � / Signature of authorized representative (by executed Power oJAttomev)
applicant -
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