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1F AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTr TOWNSHIP YEAR
�- REQUESTING DEDUCTION FROM ASSESSED VALUATION
S,W � State Fortn 43708 (RS / 6-03)
PrescnEeO by ihe Department o( Local Govemment Financa
In'ortnation contained in Nis document is CONFIDENTIAL pursuant fc1E 6-�1-i?-9. � File Mark
C ' p
RUCTIONS.' ji �`—/ ILING DATES:
To 6e filed in person or 6y mail with the Counry Auditor of the cour(�l�h �e4 2��3 1) Real properfy: Dunng fhe 12 months belore May
the property is located. 11 of the year the deduction is to be eNective.
� 2) obile homes assessed under I.C.6-1-1-7;
See �everse side foradditional instruction and qualificationil5� efween January 15 and Maroh 31 o/the year
�.
�� GIBSOtJ COU TY q�iUITOR lhe deduction is to 6e eHective.
of
or
name on record is
conbact
❑ Yes ❑ No
than that of aonlican
m
Name of conVact seller (applicant must have 6een buying on contrect at least one (1J }rear)
0
property use
r residence?
❑Yes ❑No
the applicant 65 years of age or more on December 31 of the year
ro the curtent year?
❑Yes ❑No
dicanPs date of birth (
;,�
ed by a surviving, unmartied spouse, what was the spouse's age at
time of death?
Have you filed for any
Have you filed for deductions in any
❑ Yes ❑ No
❑Yes ❑No
I wiN someone
with whom
Isthe propertyin questlon:
spouse,
❑ Real property ❑ Mobile home (I.C. 6-7-7-�
Assessed value ot the property as of March 1, curtent year (may not
exceed $144,OOOJ
Does the combined annual adjusted gross income of the appliwnt and any
individuals sharing ownership exceed 525,000? ,
� $ �-,
INJe 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 _
Add255
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of authorized
of