Age_Barrett' • 4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
r�_. „ REQUESTING DEDUCTION FROM ASSESSED VALUATION
�� ,� � i State Fortn 43708 (R6l e-Oa) �
Prescribed by ihe Depatlment of Local Gwemment Finance
�rmaUOn contained in this document is CONFIDENTIAL pursuani to IC 6-1.1-12-9 and IC 6-1.7-359.
INSTRUCTIONS:
To be filed in person or 6y mail with the County Audito� o! the county where
the property is located. -
See reverse side lo� additional instruction and quali(cations.
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FILING DATES: �sy
1J Real properfy: DuriSg t� 12Tmonths betore May
11 0/ rli��€arMlitQ/ed�5bticAilRli6)6e elfecrive.
2) Mobile homes assessed under 1.C.6-1-i-7;
between January 15 and March 31 of the yea�
the deduction is to be effective.
Name o( appli nt (owner or contract buye�) �
Is applicant the sole legal or equitable ovmer? If No, whal is his/her exact share or interest? If owned with someone other than spouse.
' indicate with whom
es ❑ No
If name on record is diReren tha that of applicanl, indicate beiow
Name ol wntrect seller (applicant must have 6een buying on confrsct at leasf one (1) year)
Address of conVact seller Is the property in questlon:
❑ Real property ❑ Mobile home (I.C. 6-1-7-7)
Taxin 'stricf i Key number / Legal description Record number Page number
/Z.Cin.C.Fi�" %-/l - /d - �- 00/. �/ / -d �2c�
Is the property used and occupied primarily for Assessed value ot the propeRy as o( March 7, current year (may nof
hisRier residence? exceed 5744,000)
❑ Yes ❑ No
Was the appliwnt 65 years of age or more on December 31 of the year poes fhe combined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ownership exceed 525,0007
❑ Yes ❑ No ❑ Yes ❑ No
AppliranCs
$
Have you filed for any other deductions? If Yes, what deducfions? .
❑ Yes ❑ No
Have you filed for deducUons in any other county? If Yes, what counryl
❑ Yes O No
I/We certify under penalty of perjury that the above and foregoing information is lrue and correct and that lhe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of authorized representative (6y executed Power ofAttomeyJ
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ess ot applicant Address of authorized representative
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