Age_Bassett°' AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTV TOWNSHIP v�,R
� REQUESTING DEDUCTION FROM ASSESSED VALUATION
� S , State Form 43708 (R3 / 8-00)
°� PresaiEeC by the SWte Board of Taz Commissioners • 3{ y �'1
In ormation contained in this document is CONFIDENTIAL pursuant to IC 6�7.7-12-9. N . F�a
&J
INSTRUCTIONS FOR FILING:
To be filed in person or by mail wifh the County Auditor o/ the county whe2 the property is loca-
ted during the 12 months before May 11 of the year the deduction is to be ef/ective.
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GIBSON COUNi1' AUDITOR
MAY 0 g 2003
Deduc6ons (or mobile homes not assessed as real property must file be[ween January 15 and
March 31.
See reverse side (or additional instrucBon and qualifica6ons.
Name of appliwni (owner orcon6act buyer) .
Is appli t the sole legal or quitable owneR If No, what is his/her exact share or interest7 If owned with someone other than spouse,
- � indicate with whom
Yes ❑ No ' '
If name on record is diBerent than thal of appGcant, indicate below
Name of contraM seller (applicant must have been buying on oontracf at least one (1) yearJ
Address of contrad seller
7axing � id Key number / Legal description Record number Page number
� ` `O� - =0_0: _ _Os Q 0
Is the real pro erty used and occupied Assessed value of the property as ot March i, curtent year (may rrot
primariry for hisTher residence? f/ exceed 569,000)
�CJ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the wrrent yearT . individuals sharing ownership exceed 525,0007
� ❑ No ❑ Yes ❑ No
ApplipnYs date of birth (month, day, yeah Source of Income Amount of Income
-
TOTAL $
Have you filed for any other deductions7 If Yes, what deductions?
❑ Yes ❑ No
Have you filed for dedudions in any other county? . I( Yes, what county?
❑ Yes ❑ No
' IIVJe certify under penalty of perjury that fhe above and foregoing information is We and wrrect and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of appiicant Signature of authorized representative (by execufed Power ofAltomey)
�reu of app ipnt Address of authorized representative
� � `� w