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! AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
F REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' State Fortn 43708 (R5/6-03) //��
M• Ptescribed by Ne Departmant of Local Govemment Rnance �{.�
Infortnation contained in this document is CONFIDENTIAL pursuant to IC &1.1-12-9. \ ,��
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COUNTY TOWNSHIP YEAR
�"RUCTIONS: FILINC, DATES:/
To be filed in person or by mail with the County Auditor o/ the county where 1) Real property: Dunng the
the property is located. 11 of the year the deduct
2) Mobile homes assessed
See reverse side for additional instrucUon and qualifications. 6etween January fb a�c
the deduction is to be efi
Name oi
name on
�
❑Yes ❑No
must have
on contract at least one
of conVact seller
a��-13 al-3�o-oa�-��8-
or
indira[e wiN
�J���
! months be%re M:
is to be effective.
ider I.C.6-1-1-7;
'aroh 31 o/the vee
MaR 2 � 2004
, :c1�.—
' ���5`v+�
Is the property in'question:
❑ Real property ❑ Mobile home (I.C. 6-14-7)
' t/V(% b-b t.� ` l
— Assessed'value�of the property as
exceed $144, 000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of ihe year
prior to Ihe current year?
❑Yes ❑No
ApplicanYs date of
_ ^
'�_— '
you filetl for any
Have you
any
❑ Yes ❑ No
year
ombined annual adjusted gross income ot the applicant and any
shanng ownership exceed 525,000?
Source of Income
If Yes, what deductions7
❑ Yes ❑ No
Amount of Income
� _o _
$
TOTAL $ �
❑ Yes ❑ No I
I/We 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 the aforementioned property on March t, 20 _
3nature of �ppliwnt �. _ Signature of auihorized representative (by executed Power o(Attomey)
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