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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rr TOWNSHIP reaR
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�. �� J State Form 43708 (R7 / 5-OB)
Presmbed by the Departrnem ot Local Gwemment Finance
• �
Information contained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC G1.1-35-9.
To beRfiled�hOperson or by mail with the County Auditor o/ the county where F 1) RealDprop�r�yPDuting th�+QP months 6e%re ��ne
the property is located. 71 of the ear the deduction is to be eHective.
2) Mobile ho �ro��{�''nder I.C.6-1-1-7;
See reverse side for additional instruction and qualifications. hee�����nu� ��5� r�yMa�ch 31 of Ihe year
N
of
applicant the sale legal or
exact share w interest?
❑Yes ❑No I
name on record is ditferent than Nat of appl" nt, indipte below
5�,� /
ame oi mnVact seiler lappl�ran m ave been ng ar contracf at least one
Iress of conVact selle�
ing disiricl
' la•��- yoa• 0o�•3ob,
ie pmperty used and oocupied primanly for
her residence?
; Me applipnt 65 years of age or more on Decv
�r to the wrrent year7
dic�anYs date of buth (month, day, yeah
ed by a surviving, unmarried spouse, what was
Gme of dea�h?
�e you filed for any ofher deducdons7
number Legal description
a
❑ No
the year
❑No
ise's age at
QYes ❑No
you filed for deductions in any other cwnly?
I( ownetl vnth saneone
indicate with whom
�__� ��.
�d value of the property as
S14a.0001
spouse,
property ❑ Mobile home Q.C. 6-14-n
number Page number
ombined annual atljustetl gross incoi
sharing ownership exceed 525,000?
/ �
❑Yes ❑No I
IlVJe certify under penalty of perjury that the above and foregoing info��t��� is true and cortecl and that the applicant was a resident
of Indiana and owner of the aforementloned property on March 1, 20
3nature of applicant Signature of authorized representative (by executed Power ofAttomey)
ss of applipnt
5 � C.�c�.
of