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�_ �_, _�� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
�> > State Form 43708 (R6 / 4-0a) �
�� • Prescnbed by iha Depatlment of Lowl Gwemment Finance
ormaUon contained in this document is CONFIDENTIAL pursuani to IC 6-1.1-12•9 and IC 6-1.1-35-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o( the county where
the propeRy is located.
See reverse side (or additional instruction and qualifications.
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FILING DATES: ��N O � ZOO�
1) Real propeRy: During the 12 months be(ore May
11 of tbe yeaFtilaMdedudl�s to 6e eflective.
2) Mo6ile hom� a`sseJssed upderl.C.6-1-1-7;
betwe�g/eQ6aQ�pS�rid �Ft��i� of the year
the deduclion is to be eHective.
Name of applic t(owner a contrecf bu r)
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Is appli t e sole legal or equi able owneR If No at is hislher exad share or interest? If owned wiih someone other ihan spouse,
' indicate wifh whom
es ❑ No
I( name on record is difterent an that of applicant, indicate below
Name of wntrect seller (applicant must have been buying on contrect at least one (1) year)
Address of contract seller Is the pmperty in question:
. ❑ Real property ❑ Mobile home (I.C. 6•7-7-�
Taxing districi Key number / Legal description Record number Page number
� P � a�-ra-o -�ol-oo�,��s- o�zd�
Is ihe property used and occupied primanty for Assessed value of iha property as of March 7, current year (may not
hisfier residence? exceed $144,000)
� Yes ❑ No
Was 1he apD����t 65 years ot age or more on December 31 of the year poes fhe combined annual adjusted gross income of the applicant and any
prior to the curtent year7 individuals sharing ownership exceed 525,0007
. Yes ❑ No ❑ Yes ❑ No
Applicanfs date of birth (month, day, year)
$ °�
Have you filed for any other deductions? If Yes, what deducUons?
❑ Yes ❑ No
Have you filed for deduclions in any other county? If Yes, what counryl
❑ Yes ❑ No
I/We certify under penalty of pery'ury 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
Signature ot appliwnt ('� I Signature of authorized representative (by executed Power oJAttomeyJ., ,
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d(�S of apphcant Address of authorized represenlative (
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