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d,,� �n„ AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
_`�s REQUESTING DEDUCTION FROM ASSESSED VALUATION
��- � ` State Fortn 43708 (R2/72-99) -
Prescnbed by ihe State Board of Tac Commissioners
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Infortnation contained in ihis documeN is CONFIDENTIAL pursuant to IC 6-1, 1-12-9.
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 72 months before May 71 of the year the deduction is to b � e.
Deductions for mobile homes not assessed as real property must fil etween nuary 15
March 31.
See reverse side for additional instiuction and qualifications. %1 �,
Is applicant ihe
If name on recc
or
al or equitable owner? If No, wh6t is
�res. ❑No
COUNTY I TOWNSHIP I YEAR
Z � si
MAY � 0 zUUU
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e � ���IT'J—.
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exact share or interesL tl owned witY,.__...�.,,rovc
indirate with whom
201U
Name of contr t seller (applicant must have been buying on contract at least one (1)
�
Address ontraci seller
�in di rict ,
Is the real property used and occupi
primarily for his/her residence?
Was the applicant 65 years of age or more on
�ear prior to the current year?
2U11
v� l�C.�c_ � l. � Q o2. J
Key number / Legal descnption Record number Page number
Q - D O�'i 7-0.0
Assessed value of the property as of March t, current year (may not
exceed 523,000)
es ❑ No /� a 7b
�cember 31 of the Does the combined annual adjusted gross income of the applicant ai
any individuals sharing ownership ezceed S25,000?
Yes ❑ No ❑ Yes ❑ No
—
�
❑ Yes ❑ No I
I/We certify under penalty of perjury that Ihe above and foregoing information is tme and correct and that ihe applicani was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signature o applirant Signature of authorized representaWe (by ezecuted Power of Attomey)
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applicant
� OU PY.`O:..i i/� .T.L
Address of authorized represeniative
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