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} AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
= REQUESTING DEDUCTION FROM ASSESSED VALUATION
t�a / State Form 43708 (R4 / 1P-01 �
Prescribe0 by ihe Depanment of Local Govemment Finance
�alion contained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of the county where
the p�operty is located.
See reverse srde for adddional instruclion and qualifications.
COUNTY TOWNSHIP YEAR
File Mar
MAY 1 �nn�
FILING DATES:
1) Real prop : Dunn th 12 nth,s 6 o ay
11 o/the ' e.
2) Mobile om�s�k�ec"�i]i�e�f.AC!6c7�-'.1- ;
between January 15 and March 31 0/ the year
the deduction is to be e/%ctive.
Name of appli (owner or wntract b e�)
r.= --� -�
Is applira sole tegal or eqwtable mmer? If No, what is hisfier exact share or inlerest? If owned with someone other than spouse,
indicate vnth whom
❑Yes ❑No
If name on rewrd is diRerenl �han thal of applicant, indiwte below
Name of contract se0er (applicant must have been buying on contract at least one (1� year)
Address of contrad seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. &1-1-n
Ta�dng di "ct Key number / Legal description Rewrd number Page number
�=9"-�-�iao7 �o�
Is Ne property used and ocwpied primarily for Assessed value of the property as of March 1, wrrent year (may not
hislher residence? exceed 569,000J
Yes ❑ No •
Was the applicant 65 years of age or more on December 31 of the year poes the comhined annual adjusled gross income o( the applicant and any
prior to ihe curtent year? individuals sharing ownership exceed $25,000?
Yes � No ❑ Yes ❑ No
Applicant'
$
If filed by urviving, unmartied spouse, what was the spouse's age at $
the Ume o death?
TOTAL $
Have you filed (or any other deductions? If Yes, what deductions?
❑ Yes ❑ No
Have you filed for deductions in any oNer county? If Yes, what county?
❑ Yes ❑ No
IlWe certify under penalty of perjury that the above and foregoing information is irue and correct and that the applicant was a resi-
denl of Indiana and owner of the aforementioned property on March 1, 20 _
Signa f applicant Signature of authorized representative (by executed Powe� o/Attomey)
�e of appiicant � Address of authorized representative
�
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