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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
� Siate Fwm 43708 �RS/ 6-03)
Prescribed 6y Ne Depamnent of Local Govemrtrent Finance
�^fortnatlon contained in this document is CONFIDENTIAL pursuani to IC 61.1-12-9.
�TRUCTIONS:. .
To be filed in person or by mail.with the County Auditor of the county wAere
the property is located.
See reverse side for additional insfruction and qualifications.
FILING DATES: I ���/,
1J Real property: Dilring th� 2 lrroiiihs be%re May
11 of the yeer the deduction is to be eHective.
2)�Mobile horries assessed under I.C.6=1-1=7;
between�a'n pary 15 and�Maroh�3i%otthe year
fhe deductiamis'tov6ereffectiveUDiTCC .
Name of appiicant (owner or conf2U 6= r�
�f��� S � /C�;
Is appliwnt the sole legal or equita6le owneR If No, what is hisRier exaa share or interest? If owned wiN someone other than spouse,
indicate vrith whom
❑ Yes ❑ No
If name on record is difterent than that ot applicant, indicate below
Name ot contraa selier (applicant must have been buying on conhact at least one (1) }rearJ
Address of conVact seller Is the property in questlon:
eal property ❑ Mobile home (I.C. 6•1-1•�
Taxing dis ' t Key number I Legal description Record number Page number
� � [O �O%"%�. -i���
ie property used and occupied primarily for — AssesseA value of Ne property as of Ma[ch 7, current year (may not
ner residence? exceed $144,000)
❑ Yes ❑ No
Was the applicant 65 years ot age or more on December 31 of the year poes the combined annual adjusted gross income ot the applicant and any
prior to the curtent year? individuals sharing ownership exceed 525,000?
❑ Yes ❑ No ❑ Yes ❑ No
Applicani's date of birth (month, day, year) _ Souree of Ineome Amount of Ineome
TOTAL $ �
Have you filed for any other deductions? If Yes, what deducGons?
❑Yes ❑No
Have you filed for deductions in any other county? If Yes, what county? r
pYes ❑No
I/We certify under penalty of perjury that the above and foregoing information is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
S�ature of licant Signature of auMorized representative (by execufed Power olAttomey)
.GC/�� /
Address of appti nt � Address of authorized representative
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