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.° � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
''L ` REQUESTING DEDUCTION FROM ASSESSED VALUATION
�> ,��� .� Stata Form 43708 (R6l4-Oa) �
Prescnbed by the Department at Lowl Govemment Finance
�rmation contained in Nis document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.7-359.
INSTRUCTIONS:
To 6e filed in person or by mail with fhe County Auditor o/ the county whe�e
the property is located.
See �everse side for additional instruction and quali�cations.
COUNTY TOWNSHIP YEAR
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File Mark �a
JUN 0 6 2007
FILING DATES:
1) Real property: Du e 12�hs before May
11 0/ the year the d�e��ucAon is toYbe eflective.
2J Mobile hor���fi�Hlu�iilehYJOT6�J1:1-7;
befween January 15 and March 31 of the year
the deduction is to be effective.
Name o( applic nl (owner or wntract buye�) �
. �
Is applirant the sole I I or quita e owner? I( No, what is his/her exad share or Interest? If owned with someone other ihan spouse,
' indicate with whom
Yes ❑ No
If name on record is diRerent than that of applicant, Indirate below
Name of contract seller (applicant must have been buying on cont2ct atleasf one (i) yearJ
Address of contract seller Is the property in ques6on:
❑ Real property ❑ Mobile home (I.C. 6-1•7-7)
Taxin district Key number / Legal description Rewrd number Page number
" �� G // /a-/o%az�do� _
Is the property used and occupied primarily (or Assessed value o( the property as of March 1, current year (may not
hislher residence? exceed 5744,000)
❑Yes �No
Was the applicant 65 years of aga or more on December 31 of fhe year poes the combined annual adjusted grass income of the applicant and any
prior to the arrent year7 individuals sharing ovmership exceed 325,0001
❑ Yes ❑ No Yes ❑ No
s
If fiied by a surviving, unmarried spouse, what was the spouse's age at $
the time of deathl
�� TOTAI. $
Have you filed for any other deductions7 If Yes, what deductions?
sYes ❑ No
Have you filed for deductions in any other county? If Yes, what county?
❑ Yes No
I/We certify under penalty of perjury that the above and foregoing informalion is lrue and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signatu � of applicant Signa[ure of authorized representative (by executed Powei ofAttomey)
v �
ress o plicani Address of aulhorized representative
O �� .- %
p� �` 5vey�� o�t�'
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