Age_Moore (5)•'�` °''v AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courrrv TOWNSHIP YEAR
ea� Z RE�UESTING DEDUCTION FROM ASSESSED VALUATION
l•s�°'y[• State Form 63708 (Fi / 9�96)
�� ' Prescribed by ihe State Board of Ta. Commissioners
� � yVV �� e Mark
Intormation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9. ��� `�! �:
7
INSTRUCTIONS FOR FILING: �
To be liled in person or by mail with the County Auditor ol the county where the property is loc� Q�L /����
ted during the 72 months before May ll ol the year the deduction is to be e/fective.
Deductions tor mobile homes not assessed as �eal property must file between January i5,and f' � (}
March 37. / � (/ I/
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See reverse side (or additional instruction and qualilications. ,/,� _�''�� . i;-y :,� ;p�TOa '
. i� ;:_.;;ON�:O�D �
Name p licant (owne� or contract bu r)
Is applican e sole legal or equitable own ? If , what is his/her e aci share of interest? If owned with someone other than spouse,
/ indicate wiih whom
�i]-v�s ❑ No
If name on record is ditterent than that of applicant, indicate below
Name o( contraa seller pli nt musi have been buying on contract af least one (7J yea�)
�
Address of contract sell r
Taxing d�
of March 1, curreni year (may not
hisfier residence? exceed 321,000)
�s ❑ No ❑ Yes fE}id�
Was the applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the appliwm and any
prior to the curren� year? individuals sharing ownership ezceed 520,000? �
❑ Yes �'IQo
ApplicanYs date of birih (month, day, year) Souree of Income Amounl of Income
�-�-
was ihe spouse's age at $
the time of death?
TOTAL $
Have you filed for any other deduciions? If Yes, what deductions?
❑ Yes ❑ No
Have you filed for deductions in any other county? If Yes, whai couniy?
❑ Yes ❑ No
I/VJe 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 the aforementioned property on March 1, 19
Signature of applicant Signature ot authorized represeniative (by executed Power olAttomey)
ess of appli nt Address of auihorized represemative . •
�G /o W,
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer G)gSON COUNTY AU OR