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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP r�eux
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S�� � Slate Form 43708 (R7 / 5-06)
Presv�bed by the Department W l ocal Gwmiment Finance
I �;'�`
Information coniained in Ihis document is CONFIDENTIAL pursuant to IC 6-1.1-72-9 and IC 6-1.7-35-9.
INSTRUCTIONS:
To 6e filed in person or by mail with the Counry Auditor o( the county where
the property is locafed.
See reverse side !or additional instruction and qualifications.
name on
�
w conbact dryer) -
� Q ��
or equitable w+neR If No, w
es ❑No
ent than that of applinnt, indicate
Narne of contract s Iler pplitant must have Deen Duy
�
Address of contract se e
- gd�stritt Ka
��rn���
Is ihe pmperty used and ocwpied primanly for
hisRier residence?
V
Was the applinnt 65 years ot age or rtrore on Decemb
prior to the artent year?
�
Applicant's date o( b'vth (rtronth, day, year)
(�-
Have you filed for deduGions ln any
exaCl Shafe Of
on contract at least one (7)
FILING DAT� �
1) Real property: L��jqg t4e�2,{p�ths 6efore �une
11 of the year tl1��iJ�d�ct n4S� be e8ective.
2) Mobile homes assessed under I.C.6-1-1-7;
between Janua�agd,�� 31 of the year
the dedu�.(i�i�N COUNTY�AUDITOR
I with someone
with whom
Is the property in
spouse,
Real property ❑ Mobile home Q.G 614-n
a l� -I a-o� -aoa-�nl.t, �a�
. Assessed value of ihe property as of Mardi 1, curtent year
❑Yes
❑ No
the year Dces t
individ
❑No
s age at
If Yes,
If Yes.
annual adjus[ed gross incw
ownership exceed 525,000?
� $
❑Yes �o I
I/We certify under penalty of perjury fhat the above and foregoing info�=}��n is Irue and correct and thal the applican[ was a resident
of Indiana and owner of ihe aforementloned property on March 1, 20 _
representalive (by executed
representative