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1 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
�` ��� � Stale Fwm 43708 (RS / 6-03)
P�esaibed by the Department of Laal Govemment Finance
In�formatlon contained in this document is CONFIDEN7IAL pursuant to IC 6-1.1-12-9.
COUNTY TOWNSHIP YEAR
File Mark
TRUCTIONS: FILING DATES:� � �--� �
To 6e filed in person or by mail with the Counry Auditor o/ the counry where 1) Real pro��rty: Duri g the 12monthr 6 fore May
the propeRy is located. 11 of the�year the deduition.isdoi6e.effective.
2) Mobile homes assessed under I.C.6-1-1-7;
See reverse side for additional instruction and qualificalions. between Januai�l5�anr1 �j� 31 0/ the year
the deduclion is to be eHective.
anolicant the
name on
contract
of conVact seller
residence?
� or contract buye�
I `
or e4uitable owneR If No. what
�'Yes ❑ No
must have been
Was Ne appllcant 65 years ot age or more on
prior to the current year?
you
you filed for deductions in any other
was
or
on cont2ct at least one (7J yrear)
es ❑ No
mber 31 of the year
�Yes ❑ No
age
❑ Yes Ql�o
GI�SON i;OU�i-Y :,i�n�T�= .
nad wilh someona other than spouse,
ate with whom
Is the property in quesdon:
[f�$IeSfproperty ❑ Mobile home Q.C. 6-7-1-n
!tl value of Ne property a5 of Marctl 1, CuRent year (may not
5744,000)
�mbinetl annual atljustetl gross Income oi the appliwnt antl any
sharing ownership exceed 525,000?
❑ Yes [�M1�o
Source oi Income Amount of Ineome
$
5
TOTAL 5
❑ Yes C3'I�o I
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 ot the aforementioned property on March 1, 20 _
olAttomey)
ss�appliwnt �° _ Address of authorized representative
�O �.�. ,�.L1 p. �