Age_ThomasN..,,na
1 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
?�r� iQ REQUESTING DEDUCTION FROM ASSESSED VALUATION
' .' State Fortn 43708 (R6 / 4-04)
COUNTY I TOWNSHIP I YEAR
� -� Prescnbed by the Department of Lora� Govemment Finance � �^�
;� i' � t1 � File Mark
� mation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC"6=1 1 35-9. i} t� }i 1
�!-d 11 li r t�J �'
INSTRUCTIONS:
To 6e filed in person or 6y mail with the County Auditor o! the county where
the property is located.
See reverse side (or additional rnstruction and qualifications.
11�Realproper`��Dunng the 12 months 6elore May
F� 11�of lhe year the deduction is to 6e effecfive.
2) Mo6i/e homes assessed under I.C.6-1-1-7;
� between Jenuary+l5 and March 31 of the year
�•L. � % .
= �tiie deduchon.is to 6e eflective.
.�.... � _ ., . .
� ,-
Name of applicant (owner ontract buyer) �
�— —�
r^ — — — _ �
Is applirant the sole legal or wtable owneR If No, what is his/her ezact sfiare or Interest? If owned with someone other than spouse,
' indicate with whom
Q Yes ❑ No
If name on record is diHerent than that of applicant, indicate below
Name of contrad seller (applicant must have been buying on rnntract at least one (1) year) •
Address of conVact seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. G1-1-�
Ta�dn district Key nur�cLLegaLdescription _ Record number Page number
� `=1-� ' =_o��. -� OO
Is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may not
hismer residence? exceed 3144,000)
es ❑ No
Was the applicant 65 years of age or more on December 31 oi the year poes the combined annual adjusted gross income of the applicant and any .
prior to fhe cunent year? individuals sharing ownership exceed 525,0001
es � No ❑ Yes 0 No
ApplicanPS date of birth (monfh, day, yeaiJ Source.of Income Amount of Income
� _ 3 $ �—
If ftled by a surviving, unmarzied spouse, what was the spouse's age at $ .
the tlme of deathY
TOTAL $
Have you filed for any other deductions? If Yes, what deductions?
❑Yes ❑No
Have you filed for deductions in any other county? If Yes, what counly7
❑ Yes ❑ No
IIVJe 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 lhe aforemenlioned property on March 1, 20 _
Signature of applicant Signature of authorized representative (by executed Power olAttomeyJ
C ���,�
ss of app nt Address of authorized representative
a
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