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ej �''v AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
` . ., .
�' State Porm 43708 (R / 9-96)
`'' Prescnbed bY the S[ate Boartl of Tax Commissioners
Information coniained in ihis dowment is CONFIDENTIAL pursuani �o IC 6-7.1-72-9.
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the Counry Auditor ol the county where the property is loca-
ted during the 12 months 6e)ore May 77 0/ the year the deduction is to be elfective.
Deductions lor mobile homes not assessed as real property must lile between January 75 and
March 31.
See reverse side for additional instruction and qualilications.
COUNTY TOWNSHIP YEAR
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APR OF� ►��
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Name of a plicant (owner or contract buyerJ ,
Is applicant the s le eg or e uitable er. If No, whai is his/her exaci share of interest? If owned with someone other than spouse,
indiCate wiih whom
❑ Yes ❑ No
If name on record is diflerent Ihan that of applicant, indicate below -
Name of contraci seller (applicant must have been buying on contract at least one (7J year)
Address of contraci seller
xing di tric Key number / Legal descripiion Record number Page number
� � Q _ pc� U - �
Is the property used and occupied primarily for Assessed value of the property as of March 7, curtent year (may not
hisfner residence? exceed 321,000) / ��
❑ Yes ❑ No y�(O O ❑ Yes LN_'No
Was the applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of ihe applicant and any
prior to the current year? individuals sharing ownership exceed 520.000?
❑ Yes 0'I�o
Applicant's date of birth (month, day, yeai)
I Have you filed for any other deductions? If Yes. what deduciions?
❑ Yes CJ No
Have you filed for deductions in any other county? If Yes, whai couniy?
❑ Yes �o
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19
Signature of applicant Signature of auihorized representative (by executed Power o7Attomey)
�dress of app6wnl Address of authorized representative