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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
SUte Fwm 63708 (RS / 6-03)
Pfescnbed by ihe Department ot Local Govemment Financa
��rtnation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
RUCTIONS:
To be filed in person o� by mail with the County Auditor of the county where ^
the property is located. �
See reverse side for additional instruction and qualifications.
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COUNTY TOWNSHIP YEAR
File Maric
FILING DATES:
1) Real property: Dunng the 12 months before May
11 of the year the deduction is fo be effective.
2) Mobile homes assessed under I.C.6-i-1-7;
between January 15 and March 31 of the year
the deduction is fo be eflective.
Name o( appiicant (ovmer or cont2U buyer)
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Is applicant the sole leg equitable owner? I( N, whai is hisRier exact share w interest? It owned with someone other than spouse,
indicate with whom
� Yes ❑ No
If name on record is difterent than that of appliwnt, indicate below
Name of conVau seller (applicant mus7 hava been buying on contract at least one (i) year)
Addrass of contrad seller Is the property in quesUon:
Real property ❑ Mobile home (I.C. 6-1-7-n
Taxing district Key number / Legal descriptlon Record number Page number
�N.51�/ lf ��/%GY�� ��
e properry used and occupied primarily for Assessed value of the property as ot March 1, current year (may nof
er residence? exceed $144,000)
❑Yes ❑No
Was tha applirant 65 years of age or more on December 31 ot the year poes the combined annual adjusted gross income of the applicant and any
prior to Ne wrtent yeaf? individuals sharing ownership exceed 525,000?
❑ Yes ❑ No ❑ Yes ❑ No
AppliwnPs date of birth (month, day, year) Source of Income AmounS of Ineome
/ ���� $
If filed by a surviving, unmarried spouse, what was the spouse's age at $
the 6me o( death?
TOTAL $ �
Have you filed for any other deduUio�s? If Yes, what deductlons7
❑ Yes ❑ No
Have you filed for deductions in any other county? If Yes, what count�?
❑Yes �No
I/We certify under penalty of perjury lhat the above and foregoing information is true and cortect and that the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant SignaWre of auihorized representative (by executed Power o/Attomey)
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Address of ap ' �t` Address of authorized representative
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