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.; 4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
i� � REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' �' SWte Fortn 43708 (R6 / 4-04) -
�' Prescnbed by Ne Depariment ot Local Gavemment Finance
�nation wntained in this document is CONFIDENTIAL pursuani to IC 6-1.1-72-9 and IC 6-1.135-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor ol fhe county where
the property is located.
See �everse side fo� additional instnrction and qualifications.
COUNTY TOWNSHIP YEAR
ile rk
FILING DATES: FEB 1 3 ZOO6
1) Real property: Dunng the 12 months be(ore May
11 of the year fhe d�ction is�be effective.
2) Mobile homes assessc��nfi"e .6-1-1-7;
6etween Jap��gp}���j�c�b��e year
the deduction is to be eflective.
Name of applicant (owner or co t buyer) .
�.�Vw r \
Is applicant Ihe sole legal or equitable owne(? If what is hisJher exact share or interest? If owned with someone other than spouse.
� indicate wiih whom
❑ Yes ❑ No
If name on rewrd is diRerent than that of applicant, indicate below
Name of contract seller (applicant must have been buying on confract at least one (1) year)
Address ot wnVact seller Is the property in question:
❑ Real property O Mobile home (I.C. 61-1-n
Taxi istrict Key number / Legal description Rewrd number Page number
� � q -0 1bD-(�o
Is the property used and occupied primarity for / Assessed value of the property as of March 1, current year (may not
hisRier residence? / exceed 3144,000)
C�'Y s ❑ No
Was the appliwnt 65 years of age or more on December 31 of the year poes the wmbined annual adjusted gross income of the applicant and any
prior to ihe current year? individuals sharing ownership exceed $25,000?
es ❑ No ❑ Yes ❑ No
�/
$
If (ded by a surviving, unmarried spouse, what was the spouse's age at $
ihe time of death?
TOTAL $
Have you filed for any other deductions? If Yes, what deductions? .
❑ Yes ❑ No
Have you filed for deductions in any other county7 If Yes, whal county?
❑ 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
of Indiana and owner of the aforementioned propeM1y on March 1, 20 _
Signature of applicant SignaNre of authorized representative (by executed Power ofAttomeyJ
.�....
e f appliwnt Address of authorized representalive •