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= AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cournv TOWNSHIP veart
�' � � REQUESTING DEDUCTION FROM ASSESSED VALUATION
�+ ✓ State Fortn 43708 (R6 / 4-0a)
Prescribed by the Department of Lowl Govemment Finance
File Mark
ation conlained in this document is CONFIDENTIAL pursuani to IC 6-7.1-12-9 and IC E1.1-359.
INSTRUCTIONS: � FILING DATES:
To be filed in person or by mail with the County Auditor o( the county where � 1) Real property: Dunng the 12 months before May
the property is located. �Q 11 of the year the deduction is to be ef/ective.
[� � 2) Mobile homes assessed underl.C.Ef-1-7;
� l� A..A........ 1........... 1C ...�iJ �/�M1� 71 �tIA� ..
oee reverse s�oe ro� aomnonai msnucr�on ana quauncanons. � u °�•^��•• °°^��v • � �••� ^•°•°° � • �• °•� ,��•
the deduction is to be effective.
Name of applicant (owner or contrect buyer) �
Is applicant the sole legal or equitabl ow e If No, what is hisfher exact e or interest? If owned with someone other than spouse,
indicate with whom
p Yes ❑ No
If name on rewrd is ditferenl ihan that o( applicant, indicate below
Name of conVact seller (applicant must have 6een buying on confract at least one (i) year) '
Address of wnlract seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6-1-7-7)
T' district Key number / Legal descriptlon Record number Page number
_ �
Is the property used and occupie primarity for Auessed value of ihe property as of March 1, curtent year (may not
hismer residence? exceed 3144,000)
❑ Yes ❑ No
Was Ne applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income o( the applicant and any
prior to the current year? individuais sharing ownership exceed $25,000?
❑ Yes ❑ No ❑ Yes ❑ No
AppliranPs date of birth (month, day, year) Source of Income Amount of Income
5
I( filed by a surviving, unmartied spouse, what was the spouse's age at $
the time of death?
TOTAL $
Have you filed for any other deductions? If Yes, what deduc8ons?
❑ Yes ❑ No
Have you filed for deductions in any other counry? If Yes, what county? �
❑ Yes ❑ No
INJe 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 the aforementioned property on March 1, 20 _
Signature of applicant Signature of aulhorized representative (by executed Powe� ofAttomey)
�ess of applicant Address of authorized representalive