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1 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE� COUNTY TOWNSHIP v�
REQUESTING DEDUCTION FROM ASSESSED VALUATION �' (�,
�+ �w J State Form 43708 (R7 / 5-OG) J
Pmxnbed by the Departrnem of Local Gwemment Fnance
I�
�ation contained in Ihis documeni is CONFIDEN7IAL pursuant to IC 6-7.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS: FILING DAT�T j 5 ZOO�
To 6e filed in person or by mail with the County Auditor of the county where 1) Real property: Dunng the 12 months before �une
[he p�operty is located. 17 o/the �4Q�d� �n is to be eflective.
2J Mo6ile h es`�`sesse nde,(d.C.6-1-1-7;
See reverse side for additional instruction and qualifications. 6et�@g�Bh�M����Ic�h'31 of the year
fhe deduction is to be effective.
Name of applicant (ovmera
�
Is appGcant the sole legal or
If name on record is ditferert
Name of conVaG seller (apF
Address of contract seiler
Taz"ug distn'cl/f �
� CJ
s the umcerN used and oa
❑Yes ❑No
ian ihat of applinn[,
must have been buying on con6act at
: the applicant 65 years ot age w more on
r to the wrrent year7
ticanYs date W birth (month, day, yea�
�
�
�e you filed for any other deductions?
�e you filed for deductions in any other cw
s ❑No
31 of the year
:s ❑No
share a
least one (7) yeaq
description
>00. - Uo
Assessed value of
exceed %144,000)
Dces the com6ine<
individuals sharing
If owned with someone other than spouse,
indicate with whom
Is the pr peRy in question: � �
Real property ❑ Mobile home (l.C. 67-1-n
ecord number Paqe number
property as of March 1, cvrrent year (may not
� � � Source of Inwme
$
Ue spouse's age at . $
�� TOTAL $
If Yes, what deducbons?
❑Yes ❑No
If Yes, what county?
of ihe appliqM and any
�Yes ❑No
Amount of Inwme
o�__
❑Yes ❑No I '
1/We certify under penalty of perjury that the above and foregoing info�**��t��n is true and crorrect and that the applicant was a resident
of Indiana and owner of [he aforementioned property on March 1, 20 _
gnaNra of �y! nt �� 0, �_ _ n Signature of authorized representative (by ezecuted Power o/AttomeyJ
Q..� (,�• D'i��.�°�` _
a (d o x 79�.
Address of auihor¢ed