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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+TV TOWNSHIP v�nrs
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S�� � State Farm 43708 (R7 / SOB) ' tl
Pmsrnbed by the Departrnent ol Lqai Gwemment Finarx,e - e�
File Mark
ation wntained in this document is CONFIDENTIAL pursuant to IC Cr1.1-12-9 and IC 6-1 J3S9.
SEP 8 2UU8
INSTRUCTIONS: FILING DATES:
To 6e filed in person or by mail with the County Auditor of the county where (\ 1) Rea/ property:��g_fh�l�.months 6efore �une
the property is located. t�' 11 o! the year he d�cliori`�to be ef/eciive.�
C. �) Mo6ile Fli�E@��3�t1TAbY�r��-�-1-7, i
See reverse side /or additional instrucfion and qualifications. O between January 15 and March 31 01 the year
�� the deduction is to be effective. ,
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u�.�� �,,��,:r�, , �me. �..�,�,.�.� �NO., - . �
" � G' �-�
anoGqnt the sole leaal or equitable ovmeR If No, what is hisTher exact share a
�Yes ❑No
If name on record is difierenl than Mat of applipn'
(applicant mus! have
m
0
(1) year)
If owned wiM someone other ihan spouse,
indicate with whom
Address of contract seller � Is the property in question: �
❑ Real property ❑ Mobile home (LC. b1-1-n
7axiny d� �cl Key number I Legal description Record number Page number
o�lv -/ot -I �-/O/ - OQD• S J�S-v
s ihe property used and ocapied primarily fw � Assessed value of Ihe property as of Marrh 7. wrrent year (may nd
hislher residence? � ezceed 8144.0001
�es ❑No
the ap�icant 65 years of age w more on Decembec3l of the year
to the current year? ,�,.,/
J�Yes ❑No
date oi birth
�
� by a survrving, unmartied spouse,
tlme of death?
�
you
any other deductions?
in any other
xas ihe spouse's age at
❑Yes ❑No
�m6ined annual adjusted gross inmme
sharing uwnership exceed 825,000?
If Yes, what
any
DYes ❑No
Source of Income Amount of Income
� �'.T.�- $ a3 �9
s
TOTAL $ >_
Yes, what county?
❑Yes ❑No f
I/We certify under penalty of perjury thal the above and foregoing info�����n is lrue and correct and that the applicant was a resident
of Indiana and owner of Ihe aforementioned propeRy on March 1, 20 _
anature of aDplicant _ Signature of authwized representaWe (by erecuted Power ofAttomey)
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A
Y7G.
Address of authorized