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� 4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'� n ` REQUESTING DEDUCTION FROM ASSESSED VALUATION
> e S�ate Fotm 43708 (R6 / 4-04)
•,.
� Prescribed by the Department ol Lowl Govemment Finance
Infortnation conlained in this document is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-1.1359.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor ol the county where
the property is located.
See reverse side (o� additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
MAY 0 4 p005
FlLING DATES:
1) Real property�9y(J ng the 12 months before May
11 of the yearifi�'de9��to be eBecfive.
2)Mo6i/e�Fg�� � u rI.C.El-1-7;
between January����i$hT9Fo/the year
the deduction is to be e/fecfive.
Name of ap IQ icant (owner or contract buyerJ �
1J
Is applicant the sole legal or equitable owner? If No, what is hisfier ct share or interestl If owned with someone other than spouse,
indicate with whom
� ❑ No
It name on rewrd is difterent than thal of applicant, indicate below
Name o( coniract seller (applicant must have been buying on writract at least one (1J year)
Address of wntraU seller Is fhe property in queslion:
eat property ❑ Mobile home (I.C. G1-7-�
�ng d�ct � Key number / Legal description Rewrd number Page number
0 3- �
Is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may not
hisRier residence? exceed 3144,000)
es ❑ No �pQ �
Was the applicant 65 years of age or more on December 31 of ihe year poes the combined annual adjusted grou income o( the applicant and any
prior to ihe curtent year? �1 / individuals sharing ownership exceed $25.0001
VJ Yes ❑ No ❑ Yes �
Appliwnt's date
Have you f�ed for any other deductions? If Yes, what deductions? .
❑ Yes LyINo
Have you filed (or deductions in any other wunty7 If Yes, wha[ county?
❑ Yes o
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 Indian nd owner of the aforementioned property on March 1, 20
Sign re of app wnt I Signature of aulhorized representative (by executed Power olAttomey)
.ress o pplicani Address of authorized representative
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