Age_Scott�-, �
d,..n•noq AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTV TOWNSHIP YEAR
REQUESTING DEDUCTION FROM ASSESSED VALUATION
Ss. — ` State Form 43708 (R2/7&99)
Prescribed by the State Board of Tax Commissioners
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File Mark
Information contained in this documeni is CONFIDENTIAL pursuant to IC 6-1, 1-12-9.
INSTRUCTIONS FOR FILING: ,�{��,'�' ' � � I• � � �
To be filed in person or by mail with the County Auditor of the county where the property is,>_ F °�•� �'� ��'�'� �
located during the 12 months before May 11 of the year the deduction is to be effective. MA� I O �Onn
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Deductions for mobile homes not assessed as real property must file between January 15 antl�n
March 31. 0
See reverse side lor additional instruction and qualilications. r �,�; .,, I!. ,
or
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Is applirani the sole legal or equitable owneR � If No, what is hislhe�xact share or interest?
If name on record is
Name of contract se
Address of cantr6ct,
!�� N° I
than ihat of applicant, indicate below
musi have been buying on coniract at least one (1) year)
Is the real properry used and occupied
primarily for his/Fier residence?
�, me appncanc o� years or age
prior to the current yeal?
Key number / Legal descripiion
��
� � � � � �/
❑ Yes ❑ No
Yes ❑ No
If filed by a surviving, unmarried spouse's age
at ihe time of death?
you flletl for any
any
❑ Yes
If owned with someone other than spouse,
indicate with whom
Record number � Page number
Assessed value of the property as of March 1, current year (may not
exceed $23,000) �� ���
❑ Yes [g#� I
!e certity under penalry of perjury that the above and foregoing information is true and correct and [hai ihe applicant was a resident
Indiana and owner of the aforementioned property on March 7, 20
Signature of applicant
Signature of authorized represeniative (by executed Power of Attomey)
of appl� Address ot auihorized representative
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