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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR M.ORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
Scate Fortn 43708 (R6l c-Oa)
Prescribad by ihe Dapanmem of Local Govemment Finance
�rmalion contained in this document is CONFIDENTIAL pursuant to IC 6•7.1•12-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
To 6e filed in person or 6y mail with Ihe CounfyAuditor of the county where
the prope�ty is /ocated.
See �everse side (or additional instruction and qualifrcations.
COUNTY .TOWNSHIP^� �(EAR
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J�pe ark Cuu�
FILING DATES: -�Ja�„ ,,�%�s-��,
1) Real property: Dunng fhe 12�or�ths�ef�ayl4ay
11 0l the year th�{ledwiiiori (���`o be e(fective.
2J Mobile homes assessed under I.C.6-1-1-7;
befween January 15 and March 31 of the year
the deduction is to be eHective.
Name ot applicant (owner or contract buyer) - ,
\.iv �n.v�� \ � �.�.M
Is applicant the sole legal or equitabie owner? If No, what is hislher exact share or interesl? If owned with someone other than spouse,
' indicate w(th whom
❑ Yes ❑ No
Ii name on record is diHerent than that of applicant, indicate below
Name of contract seller (applicant musf have been buying on confract at least one (1) }rearJ
Address of wntraIX seller Is the property in question:
❑ Real property ❑ Mobile home (/.C. 6-7-7•7)
7axing d' i Key number / Legal description Rewrd number Page number
� � -' -OU
Is ihe property used and ocwpied primariy for Assessed value of fhe property as of March 1, curtent year (may not
hislher residence? exceed 5744,000)
Yes ❑ N
Was the applicant 65 years of age or more on December 37 of year poes fhe combined annual adjusted gross income of the appiiwnt and any
prior to the current year? individuals sharing ownership exceed 525,0007
es ❑ No ❑ Yes ❑ No
ApplicanPs
_�� s $—
tl filed by a surriving, unmarried spouse, what was the spouse's age at $
the tlme of deathl
TOTAL $
Have you filed for any oNer deduclions? I( Yes, what deductions?
Yes O No O Q d
Have you filed for deductlons in any other county? If Yes, what wunlyT
s O
I/We certify 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 pplicani Signature of authorized representative (by execufed Power ofAttaney)
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i
ess of applicant Address of authorized representative