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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED
VALUATION State Form 43708 (1-90) Prescribed by the
State Board of Tax Commissioners
County � Township� Year
Instructions for filing: �;1����
To be filed in person or by mail with the County Auditor of the County where the �9
property is located during the 12 months before May 11 of the year the deduction
is to be effective. Deductions for mobile homes not assessed as real property �Y � 2 �99� '
mustme oenveen �anuary i o ana marcn a i. oee reverse ror aoomonai msuucuons
and qualifications.
Applicant (Owner or tract buyer)
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Is applicant the sole egal or If no, his/her exact share or If o ned with someone other than
equitable owner? O yes O no interest? spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
Name of contract seller (Applicant must have been buying on contract at least one (1) year.)
Address of contract seller
�� District Key Number/ , al_Res ripti _,_"�T Record No.
� _ ,� .�...m.� c � � . OC ,lti Page No.
Is the real property used an ccupied primarily Assessed value of the property as of March 1, current
for his/her residence? yes O no year (may not exceed $19,000).
Was the plicant 65 years of age or more on ApplicanYs date of birth
Dece er 31 of the year prior to the current year? �
es O no If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
Does the combined annual adjusted gross Source of come Amount of income
income of the applic t and any individuals �
sharing ownersh' exceed $15,000?
O yes
Total
Have you filed for any other deductions? If yes, what deductions?
Have you filed for any deductions in any other county? If yes, what county?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March t, 19 �
Sianature Authorized Representative (by executed Power of Attorney);_
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Addres of Applica Address of Representative
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