Age_Williams� � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'i� REQUESTING DEDUCTION FROM ASSESSED VALUATION
��d e State Fortn 43708 (R6 / 4-Oa)
Prescribed by �he Department of Local Govemment Finance
�nation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
COUNTY TOWNSHIP YEAR
File Mark
INSTRUCTIONS: FILING DATES:
To be /iled in person or by mail with the County Auditor of the county where 1) Real propeRy: Dunng the 12 months be%re May
the property is located. 11 of the year the ded 'on is to be ef/ective
See 2verse side for addiUonal instruction and quali�cafions.
name on
of conhact seller
orcontractOUyer •
or equita vmer. If No, what is hisRie act share or interest?
es ❑ No
ent than that of applicant, indicate below
onlicant must have been bwina on contract at least one (1) vead
Address of contraU seller
T n disly
Is �ne property used and occupied primarity for
his�her residence?
Was the applicant 65 years of age or more on I
prior to the curtent yeaR
App�iwnPs
� the spouse's age at
es ❑ No
2) Mo6ile homes assess d n $7(r� 6-�'7�}s�'!
between January 15 d M�(chjsl ofryg�'y•� e�
ihe deduction is to be eNectl6e$� 1L%
indicate wiih
Is ihe property in
Assessed value of the property as
exceed 3744,000)
properry ❑ Mobile home (I.Q 6-14-�
year
Does the wmbined annual adjusted gross income of lhe applicant and any
individuals sharing ovmership exceed $25,0007 �
❑ Yes .8'I�o
.
$
❑ Yes k7No �
IPNe 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
a
ress of appliwnt
�
�0��
(by executed Power olAttomeyJ