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i AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S � Sta;e Fortn 43708 (R5 / 6-03)
N�
� Prescnbatl Dy ihe Department of Local Govemment Finance
Intortnatlon contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-72-9.
INSTRUCTIONS:
To be �led in person or by mail wrth the County Auditor of fhe counry where
tbe propeRy is located.
See reverse side (or additional inshuction and qualificafions.
Name of applicant (owner or contract b
Is auolicant ihe sde leoal or equitable a
�s
If nama on recoM is diRerent than thffi c
Name of coniraa seller (applicant must
Addreu of conUaa seller
T^ i dis 'ct
�
Is the rope used and occupied p�m�
hisrtier residence?
��
If No, what is hisRier exaa share w
❑ No
for
Ne applicant 65 years oi age or more on
to the curtent year?
�
COUNTY TOWNSHIP YEAR
�
�F�)Ie Ma�
3LJ
FILINGDATES: OCT �U 200�
1) Real property: Dunng the 1�`1 monrhs e%re May
11 of the year fhe deductio/� is�to be eHectrve.
2)Mobileho � s.assessedfind�e�il.C.6-f�f-7��
between Janua — ,f5w�lv(aich�3t'o1 tNe-�ear
!i�o.,�� �,�'v� i r nUD17pR I
the deduction is to be eBective.
i someone
whom
Is the property in questian:
spouse,
Real property ❑ Mobile home (I.C. 6-1-7-n
cord number Page number
value of the property as of March 7, wrtent year (may not
44, 000)
Does the combined annual adjusted gross income of the applicant and any
individuals sharing ownership exceed 525,000?
❑ Yes ❑ No
S�ce p( Income � Amount of Inoome
the spouse's �e at ' "
If Yes, what deductic
Yes ❑ No
( Yes, what counp?
� Yes o
_ i� �
�
TOTAL � $ �
IIWe certify under penalty of perjury that the 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 _
�' (�wl..
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