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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION_ FROM ASSESSED
VALUATION State Form 43708 (1-90) Prescribed by the
State Board of Tax Commissioners
County Township Year
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Instructions for filing: �Y 0 � �g�� Mark
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 deductio ✓ � / //
is to be effective. Deductions for mobile homes not assessed as real prope ,��:i ��� �-�1��
mustfile beiween January 15 and March 31. See reverse foradditional instructi s;�;-s���a c�ou: �:"� `
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and qualifications.
Applicant ( r co ^ . '
Is applicant the sole lega If no, what is his/her exact share or If owned with someone other than
equitable owner? ❑ 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
District Key Number/Le al Description __� Record No.
�' - - ^ ;, - Page No.
Is the real property used and cupied primarily Assessed value of the property as of March 1, current
for his/her residence? ❑ no year (may not exceed $19,000).
Was the plicant 65 years of age or more on Applicant's date of birth _ ,?
Dece er 31 of the year prior to the current year?
es ❑ no If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
Does the combined an al adjusted gross
Have you filed for any other deductions? If yes, what deductions?
Have you filed for any deductions in any other county? If yes, what county?
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 on March 1, 19
S�nature Authorized Representative (by executed Power of Attorneyj ='�
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Ad ess o A pliCca��j Address of Representative
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