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;,_. ; AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTV TOWNSHIP veaR
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�O � Sute Form 43708 (R6 / 4-04) � �
�• Prescnbed by lhe Department of Local Govemment Finance �
il M
Tnforma6on contained in ihis documeni is CONFIDENTIAL pursuant to IC 6-1.1-72-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
To 6e filed in person or 6y mail with the CountyAudito� o/ the count where
the property is located.
See �everse side !or additional instruction and qualifications. �] jJ'
�LING DAT�� 2 � ZOO6
1) Rea/ property: During the 12 months be(ore May
11 of they'g� the d wction is to 6e ef(ective.
2) Mo6i/e h md'4is� es�underl.C.6-1-1-7;
be�y���jy � 31 of the year
the deduction is to be eHective.
Name o( applirant (owner or contract buyer) �
.JCN v vG.✓
Is applicant ihe sole lega or equi ble owner? I No, what is his/her exact share or interest? I( owned with someone other than spouse,
' indicate with whom
s ❑ No
if name on record is diBerent an that of appliwnt, indicate below .
Name of wntract seQer (applicant must have been buying on contrsct at feast one (7J yeer)
Address of conVact seller Is the property in question:
�-�O - - O%- �/O Y- �O � ip %,5 �� a- O Real property ❑ Mobile home (I.C. 6-1•1-7)
�'ng ''ct , Key number / Legal description Record number Page number
�C� d l -OO 6 7,5 - r�
Is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may not
hisRier residence? exceed $144,000)
❑ Yes ❑ No � y�d d
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross inwme ot the appiirant and any
prior individuals sharing ownership exceed 525,0007
❑ Yes ❑ No ❑ Yes �No
Applicanl's date of birth (month, day, year) Source of Income Amount of Income
$
If filed by a surriving, unmarried spouse, whal was the spouse's age at $
the time of death?
TOTAL 5
Have you filed for any other deductlons? If Yes, what deductions?
❑Yes ❑No
Have you filed for deductions in any olher county7 If Yes, what county?
❑ Yes ❑ No
I/We certify under penalty of perjury thai the above and foregoing information is true and correct and lhat the appiicant was a resident I
of Indiana and owner of the aforementioned property on March 7, 20 _
Signature of applicant Signature of authorized representative (by executed Powe� ofAttomey)
� '
ress o licant Address of authorized representative