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1 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP veaR
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
� � Spta Fwm 43708 (RS / 6-03)
Presfribed by Iha Department of Local Govemrtrent Finance
File Mark
Infortnation conWined in lhis document is CONFIDENTIAL pursuant to IC 6-1.1-12-9. ,��� —('
� 9,
�(RUCTIONS: FILING D T S: �` � i'
To be filed in person or by mail with the County Auditor o! the county where 1) Real property: Dunng the 72 months befo2 May
tbe property is Ixated. 11 of fhe year fhe deducNo' is ro be eflective
See 2verse side /or additional insWCtron and qualifications.
Of GOO�l2U
aoolicant Ne sole legal
Yes ❑ No
name on
must
Address ot conVact seller
J
primarily for
residence?
Ne applfCant 65 years ot age or mOre on
ro the curtent year?
date of birth (
age at
time of death?
you fileA for any
2) Mobile hartiesassessed�under I.C.6-1-1-7;
between January 15 and March 31 o/the year
the deduction is !o befeffective
, � r�i,�,...-t
�i.�.�../'"`„'ti- .�m�.1L:
• •.t,.Cqll.-�,•••.
I with someone other than spouse,
with wnom
Is the prope/rty in question:
❑ IEeal property ❑ Mobi�e home Q.C. 6-1-7-�
Record number Page number
ialue of the property as ot March 1, curtent year (may not
34,000)
93a ,Sa o d
ombined annual adjusted gross income of the applicant and any
sharing ovmership exceed 525,000?
Source of Income
If Yes, what deductions?
❑ Yes �le�
Amount of Income
5
�
TOTAL 5 �
❑ Yes L_}1Vo
Have you filed for deduMions in any other county? � If Yes, what counry?
❑ 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 property on March 1, 20 _
SignaturRof applicant Signature of autliorized representative (by axecuted Power of Attomey)
of authorized
iD�Jv�O�.