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, d�'°a AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
` ` REQUESTING DEDUCTION FROM ASSESSED VALUATION
5�-• • State Farm a3708 (R / 9-96)
';�0�' Prescribetl by ihe Stare Boartl ot Tae Commissloners
Information coniainetl in this document is CONFIDENTIAL pursuant to IC 6-1.7-72-9.
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor o) the county whe�e the property is loca-
ted during the 12 months before May 77 0/ the year the deduction is to be etfective.
Deductions lor mobile homes not assessed as real property must lile between January 75 and
March 31.
See reverse side for additional instruction and qualilications.
(owner or
applicant the sole legal or
No, what is his/her exact
�Yes �No I
name on record is differen� than ihat of applicant, indicate below
ot contraa seller (applicant must have been buying on
his/her residence?
was the applicant 65 years ot age or more on
prior ro ihe curreni year?
=d by a survivii
time of death?
Have you filed tor any
Have you
❑ No
he year
spouse, whai was the spouse's age at
uctions?
' t�Yes ❑ No
any oiher counry?
COUNTY I TOWNSHIP I VEAR
DEC 03 1998
/� �% . : n
�/ �.
Lc.c�� -I r,,�._��
/° GIBSO� C'O�ird7y AUDI7pR 1
with 5omeone oiher than 5pouse,
with whom
one (�/ year/
�iption Recard nu
S % /—�
Assessed value of the pmperty as of
exceed 527, 000)
1, current year (may not
�Yes ❑ No
Does the rAmbfnetl annual atljustetl gross inCAme of the applitant and any
individuals sharing ownership exceed 520,000?
Yes, what
of Income
$
$
TOTAL $
❑ Yes ❑ No
Amount ot Income
��OS.S
OS'_s%
❑ Yes �.No �
IIVJe certify under penalty of perjury ihat the above and foregoing information is true and correct and ihat the applicant was a resi-
dent of Indiana and owner of the aforemeniioned property on March 1, 19 _
iaNre of applicant Signature of authorized represemative (by exxuted Power o/Attomey)
of applicant
L/ O `/ •
i
Adtlress of authorized representative
0