Age_Tyree (3)i �. ^'M1 V
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, � cour+rr TOWNSHIP v�aa
REQUESTING DEDUCTION FROM ASSESSED VALUATION
- S�w 1 Sfate Form 43708 (R7 / 5-W)
Presmbtd by Ne Departrnent of LorW Govemment Finance
File
aGon contained in this document is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6- - 9. -
INSTRUCTIONS: FILING DATES: (� n p
To 6e �led in person or 6y mail with the County Auditor o! the count w Real property: D�X�thL� 1� ?��tfis 6efore �une
the property is located. 11 of the year the deduction is to be ef/ective.
2) Mobile homes as u/� 6-1-1-7;
See reverse side for additional instruction and qualifications.��y� � beRveen January 15�a Marc Dl���e year
the deductl�`��be��h%c�'
�
I`
Knameon
=r or conUad buyerJ �
/�
al or equitable owneYl If at is
❑Yes ❑No
�rent ihan that of ap�qnt, indicate below
contraG seller (applicant
hislher re5idence?
Was the applicant 65 years ol
prior to the current yeaR
ApplicanYs date oi birth (mon�
If filed by a surv'rving, unmarri
Ne time of dealh7
Have you filed for any other d
Have you filed for deduc6ons
�
age a rtrore on
spouse,
0
f
�
w interest?
at least one (1) yearJ
� -ia-o%
Yes ❑No
Jecember.31 of the year
�Yes ❑No
was Uie spouse's age at
❑Yes ❑No
3-4e%
sharing
If owned with someone o�ner than spouse,
irWicate with whom
Is the property in
Real properry ❑ Mobile home (I.C. 614-�
the property as of March 1
Source of
525,000?
urrent year (may not
ne of the appiinM and any
❑Yes ❑No
Amount of Income
$
$
TOTAL S
❑Yes ❑No �
I/We certify under penalty of perjury ihat the above and foregoing info�**+�r��n is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of authorized representabve (by executed PowerWAttomeyJ
'vv , ` � P
�.a� �t ar,ro���t Address ot auNorized representative