Age_HartN. ^�n
� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�° � REQUESTING DEDUCTION FROM ASSESSED VALUATION
� � ! State Fam 43708 (R4 / 70-01)
PrescriDeA by Ihe Department af Local Govemment Finance
�u.
COUNTY I TOWNSHIP I YEAR
I,.,rtnation contained in �his document is CONFIDENTIAL pursuant to IC 6-1.1-12-9. gN
INSTRUCTIONS: ILIN6 (iA'IES:
To be filed in person or by mail with the CountyAuditor of !he county whe�e
the property is locafed.
See reverse side for adddional instnrction and qualifications.
Mark
1J /��Aprop�y.��g the 12 montF,s 6efore May
1 � ii� fhe year e deduction is to be eHeclive_
2) Mobile h m asses d derl.C.6-1-1-7;
be ee Ja 1 d arch 31 o(the year
i ���f tive.
GIBSON CO �
Name of applicant wner or contract buyer .
� — �
Is applicant Ihe sole legal or equita e e. If No, what is hislher exacl share or interest? If owned with someone other lhan spouse,
indicate wifh whom
❑ Yes ❑ No
If name on record is diRerent than that of applicant, indicate below
Name of contrad seller (applicanf must have been buying on contracf at least one (7) year)
Address of wnVad seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6-1-1-n
Ta�dn istrict Key number / Legal desaiption Record number Page number
'� C��-= --lD-- =OC� =
Is the property used and ocwpied primarity (or Assessed value of the property as of March 1, wrrent year (may nof
hislher residence? exceed $69,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the com6ined annuat adjusted gross inwme of ihe appliwnt and any
prior to Ihe current year? individuals sharing ownership exceed 525,000?
❑ Yes ❑ No ❑ Yes ❑ No
ApplinnYS date of birth (monfh, day, year)
$
Have you filed for any olher deductions? If Yes, what deduclions?
❑ Yes ❑ No
Have you filed for deductions in any other county? I( Yes, what county?
❑ Yes ❑ No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that lhe applicant was a resi-
dent of Indiana and owner of the aforementioned propeAy on March 7, 20
Signalure of applicant Signature of authorized representative (by executed PowerofAttomey)
.ess of ap 'can " Address of authorized representative
i�