Age_WardN rt•n� COUNTY TOWNSHIP YEAR
, AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�' ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
` �w / Slate Fortn 43708 (Rd / 1P01)
Prestribed by Ihe Department of Local Govemmenl Finance
File Mark
.....rtnalion contained in this document is CONFIDENTIAL pursuant lo IC 6-1.1-12-9.
INSTRUCTIONS: FILING
To be filed in person or by mail wifh the County Auditor of the county where 1J Re pe�: �'g�2�s 6efore May
the property is located. 11 of the year the deduction is to 6e effective.
2J Mobile hoQ�s}e�sq��ierl.C.6-f-1J;
See reverse side for addRional instruction and qualifications. betw en January 15 and March 31 0( the year
tbe duction is bc� ffectiv
Name of applicant (owner or confracf buyer) GIBSON COUNiY AUDITOR
Is applicanl the sole legal or ita6le owner? If No, what is his/her exact share or interest? If owned wiih someone olher ihan spouse,
indicate with whom
❑Yes ❑No
If name on record is different ihan that of appliwnt, indicate below
Name ot contract seller (applicant must have beon buying on contract at least one (7) year)
Address of contraG seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 61-1-n
Ta�dng district Key number / Legal descrip5on Record number Page number
/ �� _�- O- =�/��
Is the property used and occupied primariy (or ' Assessed value of the property as of Mard� 1, wrtent year (may nof
hislher residence? exceed $69,000)
� Yes ❑ No
Was the applicant 65 years of age or mwe on December 31 of the year Dces the comhined annual adjusted gross income of fhe applicant and any
prior to ihe current year? individuals sharing ownership exceed $25,000?
@3'S'es ❑ No ❑ Yes
Applicant's dale of birth (
Have you filed for any other deductions? If Yes. what deduclions?
❑Yes ❑No
Have you filed for deducUOns in any other county? If Yes, what counry?
❑ Yes ❑ No
1/We certify under penalty of perjury that the above and foregoing information is true and correct and lhat the applicant was a resi-
dent of Indiana and owner of ihe aforementionad property on March 1, 20
Sign Nre of applicant Signature of authorized representative (6y executed Power o/Attomey)
1 �
ss of appGpnt Address of authorized represenlalive