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F AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP vEO,R
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�S ,w� � State Form 43708 (RS / 6-03) �
PresaiGed Dy Ne Departrnent of Local Govemment Financa
File Mark
InformaGon contained in this document is CONFIDENTIAL pursuant to IC G1.1-72-9.
-t--�—� �
UCTIONS: FILING'DAT�: 1�� � {��--j i' �
i �
To be filed in person or by mail with the County Auddor of the county where 1J Real p�perty�Dunng fhe�.l2.months belore May
the property is Ixafed. 11 0l fhe'year tbe deduction is to be effective.
2) Mobile homes assessed urjaeY I.C.6-1-1-7;
iu�.
See reverse side for additional insUuction and qualifications. between January 15 and March 31 of the year
the deduction is to be e%ctive. /1 ��
nv
r / C_�i
If No, wh i is hisRier exact share or
❑ Yes ❑ No I
name on record is different than that of appiicant, indiwte below
contract
ng disMd
�//ion
must
and occupied primarily for
the appficant 65 years of age or more on
to the cuvent year?
�
filed by a surviving, unmartied spouse, what was
e fime of death?
you
you
any
iuNng on contrect at ieast one
Key number / Legal descriptic
� O_/- -00Z3'
A
e�
Yes ❑ No
mber 31 of [he year Di
in
IX�'es ❑No
�.he spouse's age at
I(
❑ Yes P1No
UI°S`Ji':
owned wiN someone other Nan spouse,
diwte with whom
property in queslion:
eal Droperty ❑ Mobile home (I.C. 6-7-7-�
:d value of the property as
8144, 000J
combined annual
s sharing ownersl
SS
what
It Yes, what counry?
March 7, curtent year (may not
3ross income of the applicant and any
I 525,000?
❑ Yes ❑ No
Amount of Income
$
$
TOTAL 5 �
L] Yes ly�'No �
I/We certify under penalty of perjury that the above and foregoing information is true and corcect and that the applicant was a resident
of Indiana and owner of the atorementioned property on March 1, 20 _
u.
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