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9_, � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP v�+R
= REQUESTING DEDUCTION FROM ASSESSED VALUATION
t / State Form 43708 (R4 / 10-01)
Prescribed by the DepanmeN of Local Cwvemment finance
File Mark
�malion contained in this dowment is CONFIDENTIAL pursuant lo IC 6-1.1-12-9. ,
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor o/ the county where
fhe property is /ocated.
See reverse side /or additional instruction and qualifications.
Name of
Is
If name on
legal or eqyRaple ovmer?
❑ Yes ❑ No
below
contrad seller (applicanf must have been buying on
Address of wntrad
number/
residence?
O Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
prior to the curtenl year?
�s ❑ No
Applinnt's date of
spouse's age at
the time of death?
Have you filed for any other deducGons?
you
❑ Yes LJ No
any other counry?
❑ Yes LJ No
one
interest?
FILI�A�S� ���iJI�
1) al p e unng fhe 12 months be(ore May
11 of th 1(� r({��E��on is to 6e effective.
2) Mobile�f bTf`ies�assessed under 1.C.6-1-1-7;
6ehveen January Jb�and March�31 o/the year
I with someone other lhan spouse,
with whom
Is the property in quest
eal property
Record number
❑ Mobile home (I.C. 6-1-1-n
Page number
�alue of the property as of March 1, current year (may not
)� 000J
8a �d
ombined annual adjusled gross income of the appliwnt and any
sharing ownership exceed $25,000?
fj7 Yes No
Source of Income Amount ot Income
$
If Yes, what county?
$
TOTAL I $ � '� () ry �
I/We ceRify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
of authorized representative (by executed Power o/AttomeyJ
Address of aulhorized representative