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t� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S � Siate form 43708 (RS / 6-03)
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��' Ptescribed �y the Departrnent of Lxal Govemment Finance
Infortnation contained in �his document is CONFIDENTIAL pursuant to IC E7.1-12-9.
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COUNTY TOWNSHIP YEAR
File Mark
UCTIONS: FILING DATES:
To be filed in person or by mail with the Counry Auditor of the county where 1) Real property: Dunng the 12 months be/ore May
tAe properfy is located. 11 of the year the deduction is to 6e eflective.
2J Mobile homes assessed under I.C.6-1-1-7;
See �everse side for additional inshuction and qualifications. between January 15 and March 31 of the year
the deduction is to be eHective.
I5 aoDficant Ne sole legal or ui ble owneR I If No, what is hislhf
❑ Yes ❑ No
If name on record is different than that of applicant, indicate below
Name of Contract Seller (applicant must have 6een buying on contract a��
Address of conVact seller
' in istriM � � Key number I Lega
� C�=17--�
�e property used and ocwpied primarily for
er residence?
❑ Yes ❑ No
Was ihe applicant 65 years of age or more on December 31 of the year
prior to lhe current year?
es � No
ApplicanPs
(Da��
If filed by a surviving, unmartied spouse, what was the spouse's age at
the Ume of dea[h?
Have you filed for any oiher deductions?
you
� Yes ❑ No
any other county?
❑ Yes �
or
one
ownad wiN someon� otF
dicate vrith whom �:--�
u C T i 7 2003
GiJ�pN COUIJiY
praperty in quesiion:
eal proDerty ❑ Mobile home (I.C. 6-1-1-n
Record�number Paae number
the property as of March 1, curtent year (may not
Does the combined annual adjusted grass income of the applicant and any
individuals sharing ovmership exceed 525,000?
S7�Y.fi
If Yes, what county?
❑Yes ❑No
Amount of Incom
�����v o 0
$
TOTAL �5 �
I/We certify under penalty of perjury that the above and foregoing information is true and correct and ihat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
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