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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR M.ORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
State Fortn a3708 (R6I40a)
Prescnbed by Ihe Departmen� ol Local Govemment Financa
�rmation contained in Ihis document is CONFIDENTIAL pursuant to IC 6-1.�-12-9 and IC 6-1.7-359.
INSTRUCTIONS:
To 6e filed in person or 6y mail with the County Auditor of the counfy where
the property is located.
See reverse side for additional instruction and qualifications.
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FILMG DATES: !i'�a a •6�
1) Real proper����}�+ ��re May
11 of the yeai the deduction is to be eRective.
2) Mo6ile homes assessed under I.C.6-1-f•7;
between January 15 and March 31 0l the year
the deductron is to be effective.
Name of applica wnei or contracf buyer) '
Is applirant the sole legal or equitable owner? ( o, what is hisRier exact share or interest? If owned with someone other than spouse,
' indicate with whom
p Yes ❑ No
If name on record is diBerent fhan that of appliwnt, indicate below ,
Name of contract seAer (applicant must have been buying on contract at Ieast one (i) year) �
Address of conVaIX seller , Is the property in questlon: ,
Real property ❑ Mobiie home (I.C. 6-1-7-7)
Taxin i trict � Key number / Legai descriplion Record number Page number
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Is the property used and occupied primarily for Assessed value ot the property as of March 1, current year (may not
his/her residence? exceed 3144,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annuat adjusted gross income of the appiiwnt and any
prior to the current year? individuals sharing ovmership exceed 325,0001
❑ Yes O No ❑ Yes No
Appliwnfs
Have you filed for any other deductions? If Yes, what deductlons?
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Yes ❑ No �'7 ,
Have you filed for deduc6ons in any other county? If Yes, what countyl . �
❑ Yes ❑ No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident I
of Indiana and owner of the a(orementioned propeRy on March 1, 20 _
Signature ot applicant Signature of authorized representative (by executed Power ofAttomey)
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ress ot applicant Address of authorized representative I
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