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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED
VALUATION State Form 43708 (1-90) Presc�ibed by tfie
Stete Board of Tax Commissioners
Instruction§ for filing:
To.be filed in person or by mail with the County Auditor of the County where the .
property is located during the 12 months before May 11 of the year the decluction _
is to be effective.. Deductions for mobile homes not assessed as real property
mustfile between January 15 and March 31. See reverse foradditional instructions
and qualifications.
County � Township � Year
. . �. �-.._-..
File ar
4�P:` 51995
AI�DIT�� R�"�
Applicant (Owner or contract buyer) �
C'��� � E�� � �
Is applicant the sole legal or If no, what is his/her exact share or If owned with someone other than
equitable owner? �yes ❑ 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
Y" D{�trict Key Number/Legal Description Record No.
-- — -, �� - �� �o�-�� Page No.
Is the real property used and occupied primarily Assessed value of the property as of March 1, current
for his/her residence? �yes ❑ no year (may not exceed $19,000).
Was the applicant 65 years of age or more on ApplicanYs date of birth
December 31 of the year prior to the current year?
�yes 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 income Amount of income
income of the applicant and any individuals
sharing ownership exceed $15,000? -
❑ yes �( no
Total .
Have you filed for any other ded ctions? If yes, what deductions? •
� ���E��
Have u filed for any deductions in any other county? (�lO If yes, what county?
7/
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 ori March 1, 19 �
i nature Authorized Representative (by ezecuted: Powe� of Attorney)
�i� � �.-� ;
Address of Applicant Address of Representative
X . . ,.
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