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d�°'^o� 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
In�uctions for filing:
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 deduction
is to be effective. Deductions for mobile homes not assessed as real property
mustfile betweenJanuary 15 and March 31. See reverseforadditional instructions
and qualifications.
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Is applicant the �1e le r U�,, If no, what is his/her exact �4fare or If owned with someone other than
equitable owner? yes O no interest? spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
e of contract
Address of contract seller
must have been buying on contract at least one (1) year.)
Is the real property used and occupied primarily
for his/her residence? ❑ yes ❑ no
Was the applicant 65 years of age or more on
December 31 of the year prior to the current year?
O yes O no
Does the combined annual adjusted gross
income of the applicant and any individuals
sharing ownership exceed $15,000?
O yes ❑ no
you filed for any other deductions?
Have you filed for any deductions in any other county?
!a/�y¢d- /O� � Page No.
Assessed value of the property as of March 1, current
year (may not exceed $19,000).
ApplicanYs date of
/
If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
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
Signature Authorized Representative (by executed Power of Attorney)
Address
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Address of Representative