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dd`rt�'��� AFFIDAVIT OF PERSON, 65 YEARS OF�AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED
�s � � VALUATION State Form 43708 (1-90) Prescribed by the
`^� �• State Board of Tax Commissioners
�
Instructions for filing:
To be filed in person or by mail with the County Auditor of the County where the
property is located during the 12 months before May 11 of the year the deduction
is to be effective. Deductions for mobile homes not assessed as real property
mustfilebetweenJanuary 15and March 31. See reverseforadditional instructions
and qualifications.
County Township Year
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File Mark
�t � � � � ���
! 1 �
'APR 181994
i , �
Applicant (Ow�er or contract buyer) • ''
U T
Is applicant the sole le or f no, what is i her exact sh If owned with someone other than
equitable owner? yes � no interest? spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: '
Name of contract seller (Applicant must have been buying on contract at least one (1) year.)
Address of contract seller
xi � istrict Ke Number/Legal Description Record No.
- 33 g Page No.
Is the real property used an ccupied primarily Assessed value of the property as of March 1, current
for his/her residence? yes ❑ no year (may ot exceed $19,000).
Was the applicant 65 years of age or more on ApplicanYs date of birth _ _
Dece 31 of the year prior to the current year?
yes � no If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
Does the combined annual adjusted gross Source of income Amount of income
income of the applicant and any individuals ' �
sharing owner exceed $15,000?
❑ yes no 3
Tota� '755.0(�
Have you filed for any other deductions? If yes, what deductions?
Have you filed for any deductions in any other county? If yes, what county?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
� n ture ' Authorized Representative (by executed Power of Attorney)
�, �- �"
Address o pplicant Address of Representative
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