Age_Roney (3),
3 �� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP ven,R
��'� REQUESTING DEDUCTION FROM ASSESSED VALUATION QG
� �.° Stata Fortn 43708 (R6 / 4-04) d�f
Presaibed by Ihe Department of Local Govemment Finance �
�
�ation contained in ihis document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1359.
INSTRUCTIONS: FILING DATES: MAR Z 9 ZOOE
To be �led in person or 6y mail with the CountyAuditor of the county where
the propeRy is located.
See �everse side tor additional instruction and qualifications.
1) Real property: During the 12 months 6efore May
11 of the year th��de�uctiR,m� o.. be effective.
2) Mobile homes 3ssess� und�.C.6-1-1-7;
between ,f��Lp1FS�a'dtl7Ll'alc41G9T0Rthe year
the deduction is to be elfective.
Name of applicant (own or contract buyerJ � I
� �.
Is applicant ihe I egal or equitable owner? If No, what is h' er exact share or interesl? If owned with someone other than spouse,
' indicate with whom
p Yes ' ❑ No
If name on record is diBerent ihan that of applicant, indiwie below
Name o( contract seller (applicant must have been buying on contract at least one (i) year)
Address ot wntract seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 67-7-n
Taxing di ct Key number / Legal descripli Record number Page number
y��„x�-�i>c� oi9- oa�9 �
s the property used and occupied primarity for Assessed value of the property as of March 1, curtent year (may not
hisRier residence? exceed 5744,000J
❑Yes ❑No
Was the appliwnt 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of Ne applicant and any
prior to the current year? individuals sharing ownership exceed $25,0007
❑ Yes ❑ No ❑ Yes ❑ No
AppliwnPS date of birth (month, day, year)
Have you Lled for any other deductions? I( Yes, what deductions7
❑ Yes ❑ No
Have you filed for deductions in any other couniy? If Yes, whal wunty?
❑ Yes ❑ No
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Si9nature o( applicant � Signature of authorized representative (by executed Power o7Attomey)
.� f i ` `'
-•e� appliwnt �� r e Address of authorized representative ' '
� �/�