Age_Bolden�i .,_.n,•`� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
" REQUESTING DEDUCTION FROM ASSESSED VALUATION
�O � SWte Fortn 43708 (R6 / S-Oa) �
Prescnbed by ihe Depanment of Lowl Govemment Finance
�rmalion wniained in ihis document is CONFIDENTIAL pursuant lo IC 6-1.7-12-9 and IC 6-7.7-35-9.
INSTRUCTIONS:
To be filed in person or 6y mail with the CountyAuditor o( the county whe�e
the propeRy is lowted:
See �everse side !o� additional instruction and qualifrcations.
COUNTY TOWNSHIP YEAR
r � � F�rk
1) Real p J ��Qwin�qy�e 12 months before May
11 of the�ear the de�yc�ion is to be elfective.
2) Mo6ile homes assessed under I.C.6-1-1-7;
between �anua,ry;lS;and Maroh 31 of the year
the deduction�s to be7e(fective.
GIBSON COUNTY AUDITOR
Name o( applicant (owner or contract uyer) � ��Q /
Is applicant the sole legal or equitab owne . If N at is hi er exact share or interest? If owned witfi someone other ihan spouse,
' indicate wifh whom
i�Yes ❑ No
If name on record is difierent than fhat of applicant, indicate below
Name of wntracl seller pplicant musf have been buying on confrsct at least one (1) yearJ
' l �
Address of conVact sel r . Is the property in questlon:
Real property ❑ Mobile homa (I.C. 6•1-1-7)
T'ng stn t Key number / Legal description Rewrd number Page number
� (� l9-b aio-o
Is lhe property used and occupied primarity for Assessad value of the property as of March 1, current year (may not
hisfier residence? exceed 5744,000)
es ❑ No •
Was Ihe applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the apPlicant and any (
prior to the current year? individuats sharing ownership exceed 525,000?
�Yes O No ❑ Yes � No
ApplicanPs date of birth (month, day, year) Source of Income Amount of Income
' � S
If filed by a surriving, unmarried spouse, what was ihe spouse's age at � g
the time of dealh�
TOTAL 5
Have you filed for any other deductions7 if Yes, what derductions?
�Yes �I No L"'� ' I ��
Have you filed (or deductions in any other county? If Yes, whal wunty?
❑ Yes
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of appliwnt Signature of authorized representative (by executed Powei olAttomey)
ress of licant Address of authorized represenlalive � � �
`° �0 3 � .� p� �:
�6��.