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� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�` � State Fortn 43708 (RS! 6-03)
�w�
Piascribed by Ne Departrnent of Local Govemment Fnance
Intormation conWined in this document is CONFIDENTIAL pursuant to IC 61.1-12-9.
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor o/ the county where
the property is located.
See reverse side lor additional insUuction and qualifications.
Name of applicant (owne� or cont2ct buye� ��/ �
�/ �
Is aooliwnt Ne sole leaal or equitable owneR If No, what'ip
(i
❑ ❑ No
If name on rewrd is difrerent than hat of applicant, indicate below
and ocwpied
or
COUNTY TOWNSHIP YEAR
File Mark
FILING DATES:
1) Real property: During the 12 months before May
11 of tAe year the deduction is to be eflective.
2) Mobile homes assessed under I.C.6-1-1-7;
6elween January 15 and Maroh 31 0/ the year
the deduction is ro 6e eH ctive. ,
NUV i p 2UO3
must have been buying on contract at least one (1) yearJ
❑ Yes ❑ No
the applicant 65 years of age or more on December 31 ot the year
tothe current year?
❑ Yes ❑ No
filed by a
e tlme of
you
you
Is the property in
� Real property ❑ Mobile home (I.C. 6-7-1-�
property as of Marcn t, curtent year
$144,000)
Does Ne combinetl annual atljustetl gross incor
individuals sharing ownership exceed 525,000?
riving, unrhartied spouse, what was the spouse's age at
N?
for any other deductions? If Yes,
❑Yes ❑No
for deductions in any other county? If Yes,
❑ Yes ❑ No
of Income
any
❑ Yes ❑ No
/imyunt of Income
5 �'%o3�S
� �
TOTAL I � �
INJe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
executed Power olAttomey)
�/a��.�