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F AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rv TOWNSHIP vEna
REQUESTING DEDUCTION FROM ASSESSED VALUATION
� S,�� � State Fwm 43708 (RS / 6-03)
Presuihed by Ne Department of Local Govemment Finance ����1
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Information comained in this document is CONFIDENTIAL pursuant to IC 6-1. 9. ��� File Mar1c
�RUCTIONS: - O C T Z �{�g DATES:
To be �led in person or 6y mail with the Counry Au r counry where 1 1) Real p�operty: Dunng the 12 months before May
tbe property is located. '/� 11 0/ tbe year the deduction is [o be effective.
� /��/ �� �,�� Mo��vines assessed under I.C.6-1-1-7;
See reverse side lor additional instruction and qu ' � iohs. , GIBSON COUN7Y Al��^I�anuary 15 and March 31 of the year
\ / the deduction is to be eflecfive.
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Name of applicant (owner or contract buyer)
Is auolicant tha sole legal or equitable ownefl If No, what is hisRier exact share or interest? If owned vrith someone other than spouse,
indirate with whom
Yes ❑ No
If name on record is diRerent than Nat of applirant, indicate below
Name of conVact seller (applicanf must have bcen buying on contracf at least one (7) }rea�J
Address of conVact seller Is the property in question:
�Real property ❑ Mobile home (I.C. 6-7-7-n
Taxing istnct � Key number I Legal description Record numbar Page number
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�e property used and ocwpied primarily for Assessed value of the property as ot March 1, wrtent year (may not
er residence? exceed 5744,000)
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 appiicant and any
prior to Ne current year? individuais sharing ownership exceed 525,000?
�Yes ❑ No ❑ Yes ❑ No
Applicani's date of birth (month, day, year)
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Have you filed for any oiher deducUons? If Yes, what deductlons?
❑Yes ❑No
Have you filed for deductions in any other county? If Yes, what wunty?
❑Yes ❑No
IIVJe 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 applicani Signature of authaized representative (by executed Power o7Attomey)
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Address of applicant Address of authorized representative
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