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dj R'"o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
s, � RE�UESTING DEDUCTION FROM ASSESSED VALUATION
�+� �• State Form 43708 (R / 9-96)
' ,���-' Prescribed 6y the State Board of Tax Commissionere
Information coniained in ihis document is CONFIDENTIAL pursuant to IC 6-7.7-12-9.
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the Counry Auditor o/ the county where the property is loca-
ted during the 12 months before May 71 0/ the year the deduction is to be el/ective.
Deductions for mobile homes not assessed as real property must lile beRveen January 15 and
March 31.
See reverse side lor additional instruction and qualifications.
COUNTY I TOWNSHIP I YEAR
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MAY 0 6 1999
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Name of applicant /owner or contract buyer)
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Is applicant the sole le I or itable owner? If No, w t is hi xact share of inierest? If,o ed with someone other ihan spouse,
indirate with whom
es ❑ No
If name on record is diHerent than ai of applicant, indicate below
Name of contraci seller (applicant must have been buying on contracf a( least one (1) year)
Address of contraci seller
Taxing district Key number / Legal description Record number Page number
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Is the property used and occupied primarily for Assessed value of the property as of March 7, current year (maynot
hisRier residence? exceed $27,000)
❑No ❑Yes
Was the applicani 65 years of age or more on December 37 of the year poes the combined annual adjusted gmss income of ihe applicant nd any
prior to the current year? individuals sharing ownership exceed $20,000?
❑ Yes ❑ No
Applicanl'
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Have you filed for any oiher deductions? If Yes, what deductions?
1�
es ❑ No
Have you filed for deduclions in any other county? If Yes, what counry? `
❑ Yes L
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of ihe aforementioned property on March 7, 79 _
Signature of applicant Signature of authorized representative (by execu(ed Power olAttomey)
(ress of appli i Address of auihorized represeniative
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