Age_Simmons (3),...,4
7.,_, .� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm� TOWNSHIP vea,R
' REQUESTING DEDUCTION FROM ASSESSED VALUATION
�> ,��� .� State Form 43708 (R6 / 4-Oa) �
Presaibed by the Departmeni of Local Govemment Pinance
rmation wntained in this document is CONFIDENTIA� pursuant to IC 6-1.1-12-9 and IC 6-1.7-35-9.
File Mark
INSTRUCTIONS:
To be filed in person o� by mail with the County Auditor o! the counfy where
the property is located.
FILING C 1 �T S� � � �
i) Real property: Dunng the 12 months 6efore May
2)iMob7e hoe�s as�e�ueSfiWider�l.C.6-1-i t� e.
See reverse side /o� addifional instruction and qualificafions. 6ehveen J n ary 15 and March 31 of the year
the deduct��ive.
Name of applicant (owner or contr ct buyer) • �
�
Is applirant the sole legal or equitabie own . If No, what is his/her exact share or interest? I( owned with someone other than spouse,
indicate with whom
es ❑ No
If name on record is difierent fhan ihat of appliwnt, indicate below
Narna of contract seller (app/icant must have been buyrng on contract at least one (1) year)
Address of contract seller Is the property in question:
` O p 3 ❑ Real property ❑ Mobile home (/.C. 6-1-1-7)
Taxing district Key number / Lega descriplion Rewrd number Page number
a - -o -ae�-oo�. �oas
is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may not
hisltier residence? exceed $144,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to fhe cunent year? individuals sharing ownership exceed 525,0001
❑ Yes ❑ No ❑ Yes ❑ No
Applicanl's date of birth (month, day, year)
$
Have you filed for any other deduIXions? If Yes, what deductions?
❑ Yes ❑ No
Have you filed for deductions in any other county? I( Yes, what county?
❑ Yes O No
IPNe 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 _
Sign� applicant Signature of authorized representative (by executed Power ofAttomey)
�
� �
ress of applicant Address ot authorized representative "
, o Nv' C�1�sC�'"`i \ �