Age_Warren. �� �
�" °'°a AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cout+TV TOWNSNIP VEAR
�i ^` REQUESTING DEDUCTION FROM ASSESSED VALUATION — /'�
� 4��• �' SWte Form 43708 (R / 9-96) /l� \1
'�,e�� �' � Prescribed by ihe State Board of Tas Commissioners -�� �-.� e-.� O v
Inbrmation contained in this document is CONFlDENTIAL pursuant to IC 6-7.1-72-9. • ile t1Aac�c {J �;
1� 'a .� N-
INSTRUCTIONS FOR FILING:
To be fi/ed in person or by mail with the County Auditor of the county where the property is loca- F E B � 1 2��Q
ted dwing the 72 months belore May 71 0/ the year the deduction is to be eflective. /� '
Deductions lor mobile homes not assessed as real property must lile beRveen January 15 and /�� ( v �
March 31. ptJ ��
See reverse side for additional�"
�.
Name of applicant (owner
Is applicant the sole legal or
If No, what is hislher exaci share of interest?
r'�❑No
If name on record is diNereni Ihan Ihat of applicanL indicate below
of contrad seller (applicant must have been buying on contract at leasr one (1) year)
.
properiy use
r residence?
�-1�- I
ihe appllcant 65 years ot age or more on
to the currenhyear? _ ,
Yes ❑ No
�ember 37 of ihe year
� �
� �/
ie time of death?
ave you filed for any other deductions?
you filed for deductions in any other
spouse's age at
❑ Yes
whom
m
�
spouse,
Assessetl value of the property as ot March 1, current year (may nof
exceed 321,000) ��
❑ Yes .QNo
Does the combined annual adjusted gross income of the applicant and any
individuals sharing ownership exceetl 520.000?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and ihat the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19
of authorized represeniative
F�� Fil.�C�...+J
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