Age_Estes��� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP vea.R
°� REQUESTING DEDUCTION FROM ASSESSED VALUATION
�� .% SUte Fartn 43708 (R6 / 4-04)
Presaibed by Ne Department of Lowl Govemment Finance
File Mark
�matlon wntained in this document is CONFIDENTIAL pursuant to IC 6-1.7-12-9 and IC 6-1.135-9.
INSTRUCTIONS:
To 6e filed in person or by mail with the CountyAuditor o( the county where
the propeRy is located.
See reverse side lor additional instniction and qualifications.
of applicant (owner or contracf buyer)
owner?
❑ Yes ❑ No
If name on record is diBerent ihan ihal of applicant,
coniract
ot contract seller
and occupied primarily (or
the appliwnt 65 years oF age or more on
to the current year?
If fded by a survivi
the fime of death?
you
(month, day, yearJ
spouse,
any other deductions?
you filed for deductions in any other
what is hisRier exact share or interest?
on contract at leasf one (1) year)
I C.J l —I ' C,
❑ Yes ❑ No
mber 37 of ihe year
❑ Yes ❑ No
was the spouse's age at
❑ Yes ❑ No
nty?
� Yes ❑ No
FILING �S� � � �
1) Rea property: Dudng the 12 months be(ore May
11 of the yea( EjtP �d�cty�� to be effective.
2) Mo6ile horri���l�ss sse�un erl.C.6-1-1-7;
between January 15 and March 31 0l the year
the deducti�tnbe�fR�live.
i someone
whom
Is the property in question:
spouse,
❑ Real property ❑ Mobile home (I.C. 6-1-1-7)
Rewrd number Page number
ad value of the property as o( March 'I, curtent year (may not
3144, 000)
e wmbined annual adjusted gross income of the applicant and any
als sharing ownership exceed $25,OW?
❑ Yes ❑ No
$
IIWe certify under penalty of perjury lhal the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20 _
of
of
y ?b ��
authorized represenlative (by executed Powe� olAttomeyJ