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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
County Township Year
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Instructions for filing: �Y jFile�ark
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 ik='-�•�-� �•�
must file between January 15 and March 31. See reverse for additional instructions �'"'� �'��'� �� su_droa
and qualifications.
A lica t(Owner.or contract buyer) ,
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Is applicant the sole legal or If no, wh�e.u�ct share or If owned with someone other than
equitable owner? �s O no interest? spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
Name of contract seller (Applicant must have been buying on contract at least one (1) year.)
Address of contract seller
` ing Di�trici Key Number/Legal Description Record No.
� � _=Q - - --� Page No.
Is the real property used and occupied primarily Assessed value of the property as of March 1, current
for his/her residence? ❑ yes O no year (may not exceed $19,000).
O yes ❑ no If filed by a surviving, unmar ed spouse, what was the
spouse's age at the time of death?
.Does the combined annual adjusted gross Source of income Amount of income
income of the applicant and any individuals
sharing ownership exceed $15,000?
❑ yes �no
Total
Have you filed for any other deductions? If yes, what deductions?
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Have you filed for any deductions in any other county? If yes, what county? ��
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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
�nature Authorized Representative (by executed Power of Attorney)
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Address of Applican Address of Representative `
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