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`��" AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE� COUNTY TOWNSHIP venR
�- } REQUESTING DEDUCTION FROM ASSESSED VALUATION n
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S�ate Form 43708 (R3 / 8-00)
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Prexribed by ihe State Board ot Ta�c Commissioners
•rtnation contained in Ihis document is CONFIDENTIAL pursuant to IC 67 J-12-9. ��� �
INSTRUCTIONS FOR FILINC,:
To be filed in person or by mail with the County Auditor of the county where the property is loca- A� R � 2 Z���
ted dunng the 12 months be(ore May 11 of the year the deduction is to be effective.
Deductions (or mo6ile homes not assessed as real property must file befween January 15 and
March 31.
See �everse side /oradditional instruc6on and qualifica6ons. GI9SOV COUNTY F.UDI70R
Is applicant the sole
If name on record is
Name of contrad se
Address of contrad
or contract
�s O No
Is the real property used and occupied
primarily for hisTher residence?
on contract at least one (i) year)
/
�s ❑ No
Was the applicant 65 years of age or more on December 37 ot the year
prior to the current yea(7
❑ Yes ❑ No
ApplipnYs date of
�
If filed by a surirving, unmarried spouse, what was the spouse's age at
the time of death?
you filed for any other deductlons?
you
any
❑Yes ❑No
❑ Yes ❑ No
I with someone other
with whom
Record number
spouse,
Assessed value of the property as of March 1, wnent year (may nof
exceed $69, 000)
Does the combined annual adjusted gross income of the applicant and any
individuals sharing ownership exceed 525,0007
❑ Yes ❑ No
Source of Income A ount of Income
$ /a �� a
$
TOTAL $
I( Yes, what
I/We certiy under penalty of perjury thal the above and Toregoing information is true and correct and that the applicani was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
�aWre of applicant ^ Signaiure of author¢ed representative (by executed Power ofAttomey)
of authorized representative
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