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"' a APPLICATION FOR SENIOR CITIZEN cou TOWNSHIP rena i
PROPERTY TAX BENEFITS � �
` —,• Sfab Fortn 43708 (R9 / 9-08)
� �.� Prascribed by the DepartmeM of Locel Govemmem Firance �
F' ark
Infwrtietiom m�tained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 anC IC G1.1-35-9. �E 8 L U)�
INSTRUCTIONS: �y,,
To 6e �led in persm or 6y mail with fhe CouMyAUdRa ol fhe county whera the pvoperty is located. G��G� �5�,
Filing Da�s: 1) Real P�opeRy: Dunng the tweNe (72) mmths belore Decem6er 37 olfhe year the deduction is toLQ6�(f�j�ivL,C ��T �
2J Mobile Hortres essessed urrtler IC 61.1-7 or manWectured hanes rrot assessed es real property: Dunrg the hvelJe (1Y2)'�nid{r�aR
belae Marci� 31 07 tha year the tletluc6on is fo 6e e%ctive.
See reverse side (a adtlifional insWCtions eiM qualifications.
Type W beneft repuested �eese dieck a0 Net apply)
�Over 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credit
Name o( ap�lifaM (owner ar canhaU DuyeQ
`y�.-��� c , �i�-
b a00ticam tha sde lepal or aQUilade ameR If No, whal is hisTher ezact share w interesl7 tt ovmed with srnneone o1�er Ihan spousa.
irWimte witti whom
❑ Yes ❑ No
tl name on racoN is difta�erit Man Ihat d applitan� iMicate 6elaw
Name of wntrzct seller (apy'rcant musf here Gaon Ouying m conf2ct af least ono (1J yee�
Pddress of mntrad seller (numbar a� sbeaC city, 5fefo. aM ZIP cotle) Is tha pmoeM �n Question:
� Real property � Mobile home'(IC 64-7-�
� Ta�ing tli na Key n�mbar I Legal deacnolion Record numSer Page nu'rher
� o�-� !� -a o-d �- yoo _ 000. 098-00,
Is the O�PeM used aM ottupied primarity for I Assassed value ot the D�oOerry as of March 1, curtem year (may rrot orceetl 5182,d30
hisrher rasidanw7 !or Orer 65 doduGian. � 5160,000 !or fhe Over 65 Ci�cuit &oaker Credi�
�Yes ❑ No
Was t�a eDO��m 65 yeara of a8e or mora on Decamber 31 of the year AOO��m�Ps date o( binh (mantA, day, yoaQ If fdea Cy a surviving. un:ramea sxuse,
pna� to Ihe wrreM yeaR wlat was the spouse's age at t�e time
�',�5 ❑ No
��
Have you fJed fw deductions in any dher cwrity7 If 19a, what courrty?
❑ Yes ❑ No
I/We certify under penalty of perjury lhat Ihe above and foregoing in(ormation is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 -
Signaturedaepfieaen PdCressotaoDGpnt (nwnGOreiMstroo4eiy,sfate,ar�EZlPmde)
�� �'. �-u.cD�� S S3 � 5 7 S � /.bc�� �l� � ,c>c� lit-�61
Signature d euthonzed represerrtativa Addrass of aNhorimd rep�esentative (numberarrd sfrec4 ury, sfato, and LPcoOO)