Age_Baylerej °'"o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�t RE�UESTING DEDUCTION FROM ASSESSED VALUATION
• State Form 43708 (R / 9-96)
"��' Prescribetl by the State Boartl of Tax Commi55ioner5
Information comained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS FOR FILING:
COUNTY TOWNSHIP YEAR
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F�e Mark
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To be liled in person or by mail with the County Auditor ol the county where the property is loca-
ted during the 72 months before May 77 of the year the deduction is to be ellective. �R I� [u�Q '.
Deductions )or mobile homes not assessed as real property must lile between January 75 and
March 31. � � �� fJ n
See reverse side for additional instruction and qualilications. �c-!ti� J',t;1• �:�.�:!� _c�'�
. � 013.°,GN C`iuh:TY 1;U^!;C?4
Name of applicani (owner contrac( buyer �� � �� ,., n
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Is applicant Ihe s e legal or equitable owner? If No, whai is his/her exaci share of imerest? If owned with someone other than spouse,
indicate wiih whom
es ❑ No
If name on record is diflerent ihan ihai of applicant, indicate below
Name of contract seller (applicant must have been buying on contracf at leasr one (7) year)
IAddress of contract seller
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. g istrici � Key number I Legal description Rewrd number Page number
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Is the properry used and occupied primarily for Assessed value of the property as of March 7, current year (maynot
hisfier residence? exceed $27.000)
Yes ❑ No ❑ Yes No
Was ihe applicant 65 years of a9e or more on December 37 of the year poes the combined annuai adjusted gross income of ihe applicant and any
prior to ihe current year? C individuals sharing ownership exceed 520,000?
C S ❑ Yes ❑ No
Applicant's date of
$
Have you filed for any other deductions? If Yes, what deductions?
O Yes O No
Have you filed for detluctions in any other county? If Yes. what county?
❑ Yes o
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the atorementioned pwperty on March 1, 19 _ a�
Signature of applicant Signature of authorized representative (by execu(ed Power o7Attomey)
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� Address of appliwnt Address of authorized representative
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