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i�,., t AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR M.ORE, courm TOWNSHIP veart
` REQUESTING DEDUCTION FROM ASSESSED VALUATION 6� �
�O ,��� � State Fortn d3708 (R614-04) ' �
���' Prescribed by lhe Depanment of Local Gavemmeni Finance
rtnation wntained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
INSTRUCTIONS: FILING DATES: �UN O G ZOO�
To be filed in person or by mail with the County Auditor of the county where
the p�opeRy is located.
See �everse side fo� additional instruction and qualifications.
1) Real pioperty: During the 12 months before May
11 o(the yea�G9�edt�aijei,ti,is to be effective.
2) Mobile homes assessed utiderl.C.6-1-1J;
6etwe�afia'�r�i�riil MiliiF�i of the year
the deduction is to 6e effective.
Name of applicant wner or contract buyer)
/ �
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Is applicant the sole legal or equitable owner? If No, what is his/her exad share or Interest? If owned with someone other than spouse,
' indicate with whom
Yes ❑ No
I( name on record is diHerent an that of applicant, indicate below
Name of wntroct seller (applicant must have been buying on contract af least one (7) year)
Address o( conVact seller Is the property in question:
�Real property ❑ Mobile home (I.C. 6-1-7-7)
Taxing district Q��/C� j(j� Key number / legal description � Rewrd number Page number
aGi� oSs�oa aoa, cia aa-
Is the property used and occupied rimarity for Assessed value of tha praperty as o( March 1, curtent year (may not
hisRier residence? exceed 5744,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the wmbined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ovmership exceed 825,0007
Yes ❑ No Yes O No
AppliwnPs date of birth (monfh, day, yearJ
$ /,�
Have you 51ed for any other deductions? If Yes, what deductions?
❑Yes ONo
Have you 51ed for deductions in any other county? I( Yes, what counry?
❑ Yes ❑ No
I/We ceAify under penalty of perjury fhat fhe 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 _
Signat of applicant Signature of authorized representative (byexecufed PowerolAttomey)
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ress of applicant � -- . Address of authorized representative I
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