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,.•°'"o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
a�� REQUESTING DEDUCTION FROM ASSESSED
VALUATION State Form 43708 (1-90)
•• State Board of Tax Commissioners
Ir�Cictions for filing:
To be filed in person or by mail with the County Au r
property is located during the 12 months before M 1
is to be effective. Deductions for mobile homes no a�
Prescribed b the
�
year
County Township Year
�a
�File Mark
the ����
ion
'�Y
mustfilebetweenJanuarylSandMarch3l.Seereverseforad tiohaljnstructions ��j 9 199i
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Applicant Owner or co tr t buyer) AUDITOR 0'��
Is applicant the sole legal or If no, what is his/her exact share or If owned with someone other than
equitable owner? �� no interest? spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
Name of contract seller (Applicant must have been buying on contract at least one (1) year.)
Address of coniract seller
T� Distri t ,Kay NumbedLegal escri tion __ =Wdl�= ' Record No.
�� Page No.
Is the real property used and occupied primari y value of the property as of March 1, current
for his/her residence? r es ❑ no year (may not exceed $19,000 .
I l�4 0 - � sa
Was the applicant 65 years of age or more on ApplicanYs date of birth _ �
December 1 of the year prior to the current year? �
O ❑ no If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
Does the combined annual adjusted gross Sourc of income Amount of income
income of the applicant and any individuals
sharing ownership exceed $15,000?
O yes �
Total
Have you filed for any other deductions? If yes, what deductions?
�O
Have you filed for any deductions in any other county? If yes, what county?
no
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
Siqnature Authorized Representative (by executed Power of Attorney)
� / _� �.
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Address of Applicant Address of Representative
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