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,� �,. � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
�O � SUte Fortn 43708 (R6 / 4-0a) �
• Prest+ibed by ihe DapaAment ot Lowl Gwemmant Finance
�irmatlon contained in this document Is CONFIDENTIAL pursuant to IC 6•1.1•12-9 and IC 6-'I.135-9.
INSTRUCTlONS:
To be �led in person or by mail with the CountyAudito� of the county where
the propeRy is located.
See reverse side /or additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
I
Fi ar
FILING DATES: IfII !�,n 7
1) Real property:'�Mn�fh'E f2'mbnths belore May
11 0! the year (Ilp deduction is to be eflective.
2) the dediTc�o�d73�'8//d���.C.6-1-1-7;
betwee � 1.R J the year
O
Name of applicanl (owner or conVact buyer) �
T V�/ (.v/�.c' —•. - _ ��
- -�.s , i
Is applicant the sole legal or equitable owner If No, what is his/her exad share or interest? If owned with someone other than spouse,
' indicate with whom
❑ Yes ❑ No
If name on record is diHerenl than that o( applicant, indicate below
Name of wntrect seller (applicant must have been buying on contract at feast one (1) year)
Address of convact seller � Is the property in quesiion:
. �f{eal property ❑ Mobile home (I.C. 6-7-7-�
Taxing district Key number / Legal description Rewrd number Page number
�
Qei �6=��=-1-a--�o3=oov:��_ _ o_��: p
s the property used and occupied primarily for Assessed value of the property as of March 1, current year (may not
hisfier residence? exeeed $144,000)
❑Yes ❑No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross inwme of the applicant and any
priw to the curtent year? �� individuals sharing ownership exceed 525,0001
L7Yes ❑ No ❑ Yes ❑ No
Appliwni'
�-� $ —
If filed by a surviving, unmartied spouse, what was Ne spouse's age at $
the fime of deaih?
TOTAL $
Have you filed for any other deductions? If Yes, what deducUons? � �
❑Yes ❑No
Have you filed for deduUions in any other county? if Yes, what counry?
❑ Yes ❑ No
I/We certiy under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature ot authorized representative @y executed Power olAttomey)
d ess of applicant Address of aulhorized representative
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