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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCT�ON FROM ASSESSED VALUATION
State Fortn a3708 (R6 / 4-04)
Prescribed by ihe Department of Local Gavemment Finance
COUNTY TOWNSHIP YEAR
File Mark
ation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-359.
INSTRUCTIONS: �If�G �ATE�
To be (led in person o� 6y mail with the County Auditor of the counfy wl�ere 1) fFea prope During the 12 months 6efore May
the property is located. 11_ ojj/�e,yaar��e,�eduction is to be effective.
z� n�6i�e doA�e �� essed underl.C.E1-1-7;
See reverse side fo� additional instruction and oualifications. behveen January 15 and March 31 of the year
' the deduction�s,to be e/%ctive.
/%�rc� � �
Name of applicant (o contract buyer) � �. GIBSON COUN �� '
Is applicant the sole leg equit e owneR If No, what is hislher exact share or interest? If owned with someone other than spouse,
indicate with whom
Y s ❑ No
If name on record is diRerent ih n that of applicant, indicate below
Name o( contract s r(a plicant must have been buying on wntract at leasf one (1) year) �
P.ddress ot conVact e r Is the property in question:
❑ Real property ❑ Mobiie home (I.C. b1-1-7)
Taxing di 'ct Key number / Legal description Record number Page number
0/i -D/SS�-d a"
Is ihe prope used and occupied primariy for � Assessed value of the property as ot March 1, current year (may not
hislher residence? ezceed 3144,000)
❑Yes ❑No
Was the applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? . individuals sharing ownership exceed $25,000?
❑ Yes ❑ No ❑ Yes ❑ No
ApplicanPs date of birth (month, day, year) Source of Income Amount of Income
$
If fJed by a surviving, unmarried spouse, what was the spouse's age at $
ihe time of death?
TOTAL $
Have you filed (or any other deduciions? I( Yes, what deducUons?
❑Yes ❑No
Have you filed (or dedudions in any other county? If Yes, what county?
❑Yes ❑No � ' �
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that lhe applicant was a resident
of tndiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of authorized representative (6y executed Power olAttomey)
�j C�
/
ess of appiiwnt Address of authorized represenlative
�p I�oY � Cv� ct�G7v .