Age_Deffendall3�.n � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�" ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
� �� / Slate Fortn 43708 (R4 / 10-01)
Prescribed by Ihe �epartmem af Local Govemment Finance
�ation cantained in this document is CONFIDENTIAL pursuant to IC 6-1.7-12-9.
INSTRUCTIONS: FILING DATES: ������pp�� �—
To be filed in person or by mail with the County Auditor o! the county where 1) Real property: L�(h�"� �AB(J�s 6e%re May
the property is located. .d –• b
See reverse side (o� additional instruction and qualifications.
Name of applicant (owner or contract buyerJ
Is applicant �he sole legal or equitable owner? o, what is
O Yes ❑ No
If name on record is difterent than ihat of aooGcant. indiwte beiow
Name of
of wntrad seller
the property used and ocwpied
must have been buying on confract af least one
11 of fhe year the educfron �s to e effectroe.
2) Mobile h mes assessed under I.C.6-1-1-
between � uary�1:5 a�d AA� h 37 f t yeai
the deductiorgisto tie�effecZv
hBC1DITOR
interest? /II owned with someone olfier lhan spouse,
V dicate with whom
Is ihe property in question:
�eal property ❑ Mubile home Q.Q 6-14-n
Key number / Legal description Record number Paqe number
❑ Yes ❑ No
Was the applicant 65 years o( age or more on December 31 of the year
prior to Ihe artent year? � �
fSYes ❑ No
AppliranYS
If fJed by a surviving, unmarried spouse, v+hat was the spouse's age at
the time of death?
you
❑ Yes C�lo
Have you filed for deductions in any
fhe pfaperty 85
year (may not
Dces the combined annual adjusted gross income of ihe applicant and any
individuals sharing ownership exceed 525,000? ��
❑Yes QNo
$
❑ Yes Dd�o �
I/We certify under penaity of perjury that the above and foregoing infortnation is lrue and correct and that the applicant was a resi-
dent of Indiana and owner of lhe aforementioned property on March 7, 20 _
Signature of applirant Signature of authorized representative (by executed Power ofAttomey)
� 71 . w � . • � iy\ / / ♦ ' -
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o(aUfhoriZed