Age_Crawfordd,,...,.,
i�AFFIDAVIT OF PERSON, 65 YEARS OF
REQUESTING DEDUCTION FR ES
' ,��� .✓ State Foim a3708 (R6 / 4-04)
Prescribed by ihe Department of Lo ovemment Fin�
�rmatlon contained in this documenl i ONFIDENTIAL pursgant to IC 1
INSTRUCTIONS:
To be �led in person or by mail with the Count udit o t t�
the propeRy is located.
See reverse side (o� additional d qual cations. �
Name ot appucant (owner or convact Duye�
' ��o
�.�11 �-/ `
,
Is applicant the sole legal or equftable owner?
�Yes ❑ No
If name on record is diHerent an ihat of aoolicant.
1-^2-9^ d I 6-1.1�35-9.
Name of contract seller (applicant must have been buying on contract at least one
�h-�
�I'
1 . ■
• � .
TOWNSHIP YEAR
��� a/6
pro e� months before May
th�ye�arth���t ��eeffective.
n er .C.6-1-1-7;
een January 15 and March 31 o/the yea�
'eduction is fo be eHective.
��
If owned with someone other than spouse,
indicate with v✓hom
Is the property in question:
37 � 6a � ❑ Real properry ❑ Mobile home (LG 6-74-7)
/ Leqal descri�6on ' � I Rewrd number Page number
� property used antl occupfetl primanty tor
er residence?
n
� Yes ❑ No
Ne applicant 65 years of age or more on December 31 of the year
to the wnent year?
at
Yes ❑ No
Assessed value of the property as of March 7, current year (may not
exceed 8744,OOOJ
Does the combined annual adjusted gross income of the applicant and ar
individuals sharing ovmership exceed $25,0007
❑ Yes ❑ No
'
� ❑ Yes ' ❑ No I � �
�
I/We certify under penalty of perjury that the above and foregoing information is true and correct and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
7naturey�applicant �Signature of authorized represeniative (byexecuted PowerolAttomey)
of authorized representative
0