Age_Stevens (3)3 N, � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTr TOWNSHIP renrt
�` ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
� ��� ! Slate Fortn 43708 (R4 / 10-Ot)
Prescribed by Ne Department of Local Govemment Finance
I�rmalion contained in this document is CONFIDENTIAL pursuant ro IC 6-1.7-12-9.
INSTRUCTIONS: FILING D�: � � ��
To be filed in person or by mail wifh the County Auditor o/ the county where 1) Real pro �e��yri2A (,he,j,?,rponths before May
the property is loca[ed. 11 of the e �h� ded�ccldld#6 to be eflective.
2)Mo6il Homesassessedunderl.C.6-1-1-7;
See reverse side for additional instniction and qualifications. betw n Janu 5 a� Ma�c 1 the year
the ' e'e '
/ GIBSON COU Tv .4UDITOR
Name of applicant er or contract buyerJ
�__' _ '. �.
Is applicant the so le al or equitabie ovmer? If No, what is hishier exad share or interest? ' If owned with someone other than spouse,
indicate with whom
❑Yes ❑No
If name on record is different �han that of applicant, indicate below
Name of contract seller (applicant must have been buying on contract af least one (1) yearJ
Address of conVacl seller Is the property in question:
� Real pmperty ❑ Mobile home (I.C. 6-1-1-7)
�n istrict Key number I Legal description Rewrd number Page number
'�`V�i c _ - - - — -8�3o-i.�-S--(�C�
Is the property used and occupied primarily for Assessed value of the property as of March 1, wrrenf year (may not
hisRier residence? ezceed $69,000)
es ❑ No �
Was ihe applicant 65 years of age or more on December 37 0( the year
$
Have you filed for any other deductions? If Yes, what deductions?
❑ Yes ❑ No
Have you filed for deductions in any ofher county? If Yes, what county?
❑Yes ❑No
I/We certity under penalty of perjury that the above and foregoing information is true and correct and that the applican� was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
Sig ature of applicant Signature of authorized represenlative (by executed Power o/AttomeyJ
.r ss of a plipnt Address of authorized representative
v �- �/ � -