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_rt �� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTr TOWNSHIP YEAR
� REQUESTING DEDUCTION FROM ASSESSED VALUATION
ti�� / 51ate Fortn 43708 (RO / 10-Ot )
Prescribed by Ihe Deparimenl of Local Govemmenl finance
���rmatlon wntained in [his dowment is CONFIDENTIAL pursuant lo IC 6-1.1-12-9.
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INSTRUCTIONS FILIN ATE : s
To be filed in person or by mail wifh the County Auditor o/ the county where 1) Real pro D riog � montY,s 6elore Ma
the property is loca[ed. �� '� � y
11 of the year the deduction is to be ef/ective.
2) Mobile homes a�ssessed underl.C:6-1-1-7;
See reverse side for additional instrucfion and qualifications. be�ieen Jan a�y 15 and MaiFh 31 of the year
!he'�d�dbc�i�tp b ee ff c.trv_e�, `
Name of applicant w r or wntract buyer
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Is applicant th ie legal or equ'rfable owner? t o, what is hisAier exacl share or interest? If owned with someone other than spouse,
indicate with whom
Yes ❑ N
If name on rewrd is difierent an lhat of applicant, indicate below
Name of contrad seller �applicant must have been buying on contracf at least one (7) year)
Address of wnVad seller Is lhe property in question:
❑ Real property � Mobile home (I.C. 61-1-n
Taxing "�ct , Key nuryber / Legal desuiption Rewrd number Page number
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Is e property used and occupied primarily for -� Assessed value of Ihe property as of MarGi 1, wrrent year (may nof
hislher residence? exceed 369,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted yross income of the applicant and any
prior to Ihe curtent year? individuals sharing ownership exceed $25,000?
Yes ❑ No ❑ Yes ❑ No
Have you filed for any other deductions? If Yes, what deducGons7
❑ Yes ❑ 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 information is true and correci and that the applicant was a resi-
dent of Indiana and owner of the aforemenlioned property on March 1, 20
Signature of ap " t Signature of authorized represenlative (by executed Powero(Attomey)
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: ss of appli"�ant Address of authorized representative
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