Age_Walburn; �_�,��`s AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE� COUt�rtY TOWNSHIP veo,tt
'�. � REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' � State Fortn 43708 (R614-04) -
Prescribed by the Department of Local Govemment Finance �
r � �l�Aark
�ation wntained in this document is CONFIDENTIAL pursuant to IC 6-1.7-72-9 and IC 6-1.13 ��
INSTRUCTIONS: FI NG �T�
To be filed in person or by mail with tFie County Auditor of the county wi{ere� 1) Real prope e 12 months before May
the propeRy is located. a�� 11 of �,}�e� t��tion is to be ef/ective.
�1�7 2) Mobile homes assessed under I.C.6-1-1-7;
See reverse side for additional instrucfion and ualifications'� � betw nua �d March 31 of the year
Q• � C the d�d�Fi� pE/e(fective.
Name of app' (owner or contr t buyer)
L
Is applicant the sole legal or i e owneh
Q Yes ❑ No
If name on record is diHerent than that of applicant
Name of conVact seller (applicant must have 6een
property use
r residence?
indipte below
on conhact at least one
number / Legal description
❑ Yes CJ No
Was the applicant 65 years of age or more on December 31 of the year
prior to ihe current year?
❑ Yes � No
�'.
I( filed by a surviving, i
the time of death?
Have you filed for any
Have you filed (or ded
� �
d spouse, what was the spouse's age a
�.ductions?
❑ Yes ❑ No
n any oiher county?
❑ Yes ❑ No
or
i vnth someone
wiih whom
Is the property in question:
spouse,
❑ Real property ❑ Mobile home (I.Q Crl-1-n
Record number Page number
property as of March �, currenl year
ombinetl annual atljustetl gross Incor
sharing ovmership exceed $25,000?
ource of Income
I( Yes, what deducUons?
If Yes, what
not
ri and any
❑ Yes ❑ No
Amount of Income
$ ��
$
TOTAL I S
i/We 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
�
of authorized representative