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°`�'o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MO
�a ? REQUESTING DEDUCTION FROM ASSESSED VALI
�� � � State Porm 43708 (F / 9-96)
�y�� ' PreStribed by ihe S�ale Board o� Taa Commis5ioners
Information contained in ihis documem is CONFIDENTIAL pursuant ro IC 6-1.7-72-9.
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INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor ol the county where the property is loca-
ted du�ing the 12 months before May ]7 of the year the deduction is to be eflective.
Deductions lor mobile homes not assessed as real property must lile between January 75 and
March 37.
See reverse side Jor additional instruction and qualilications. ,
TOWNSHIP
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YEAR
Name of applicant (owner or convact buyerJ
v � �
Is applicani ihe sole legal or equitable owner? If No, what is his/her exaci share of interest? If owned with someone other than spouse,
indicate wiih whom
�es ❑ No
If name on record is diHerent ihan that of applicant, indirate below
Name of wntract seller (applicant must have been buying om m�tract at leas( one (7) year)
Address of contract seller —
�in districi � ney numoer i �egai oescnpu��� Rewrd number Page number
, �/�t-o��a/- �
Is the property used and occupied primarily for Assessed value of the property as of March t, current year (may nor
his�her residence? exceed $21,000) 1
�s ❑ No 3 v ❑ Yes CJ No
Was ihe applicant 65 years of age or more on December 31 of ihe year poes the combined annual adjusted gross income of the applicant and any
prior to ihe current year? individuals sharing ownership exceed 520,000?
❑ Yes f8"�Jo
ApplicanYs date of birth (mo th, day, year) � Source of Income Amount ot Ineome
�, _ _ SS $
If filed by a surviving, unmarried spouse, what was the spouse's age at $
the time of death?
TOTAL $
Have you tiled for any oiher deductions? If Yes, what deductions?
�Yes ❑ No � � �j )')�
Have you filed for deductions in any other county? If Yes, what county?
❑ Yes L� No
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of ihe aforementioned property on March 1, 19 _
Signature of ap1plicant SignaWre ot authorized representative (by execu�ed Power o7ArromeyJ
��ss of applicant Address of authorized representative
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