Age_Cromer': ,:
� APPLICATION FOR SENIOR CITIZEN cou sHi
PROPERTY TAX BENEFITS 1
, ' Staro Fortn 43708 (R9 / 448)
Praaaibed by Ne Depsrtmerh of Locel Goeemmefn Finance
a� 2009
Informetbm m�teinetl in this Coament is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.L35-9.
INS7RUCTIONS: 6�y
7o be filed in person or by mail with the CourriyAuditor of Ne couhty where the property is loce(ed. t�� R n�;T, �
Filiry Oeles: 1J Reel Pioperty: Durirg Ure tweNe (72) mmfhs be/Ore Decem6er 37 o/fAe ysar the deducfion is fo Ctl'B/��i7�"�+� %TY AUDITOR
2) Mobrle Homes assessed urrder IC 6t. f-7 or manu/ectured hanes rrot assessed es real ploperty: Dunrig the twulve (72) months
be/ore March 37 0/ the year fhe r/eCUCtion is to be ei/ective.
See ieverse side (or atld'Qronel inshuUions e�M qualifications.
Type of 6eireN reauested (Wease dieck e0lhaf applyj
�Over 65 Deduc6on from Assessed Valuation �er 65 Circuit Breaker Credit
Name of epd�l�+� d �a �d
�� �/�^��
Is epo��M the sde lepal or eQUitable owneR H No, w�at o hisiTer exae stiare or inte:ast? H owned with someone Uhar than 50ouse.
indimte with whom
❑ Yes ❑ No
H nama on reco�d is Ciflerartl Nen Nat d applinn� indicala bebw
Name of contratl se0er (applicanf mu5f have bemi Euyirg on cmlract et besf orw (1) yea�
� Pddrass ot mntrad sa�er (numDma�d sbeef, cify, state, aM ZIP mde) Is �he ptoPerty in dues�ion:
� Real property � Mobile home (IC 6-1-7-�
7�' al�(�7 Key numher I legal descriplan Recofd numDar Page numDer
��x� a �-�o-/s =�oo - 000. ��o -o oi
b the WopeM useO eM occupie0 primarily for AssesseE value of lhe properry as at March 7, wrtent year (may rwl exceed 5f87,d30
ha/her residente? kr O�e� 65 tlotluCion, a- 5760.000 hr Na Over 65 Grc�ut Broeker GeQi�
❑ Yes ❑ No
Wnv the e00��165 yean of age w more on December 31 of ihe year ApD��nfs date o( drth (morrth, day, ynaQ If filed Dy e survivinq, unmartieC spouse,
orror io me a,rrem yean what was lhe spouse's aga at LSe time
�Yes ❑ No � ord�mv
Adjusted gross income of applicant, spouse, and any
� Yes � No .
Mava you Aed far dedudions in any other muMy7 If lea. what couMy't
� Yes ❑ No
IIWe certi(y under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a residenl
of Indiana and owner of lhe aforementioned property on March 7, 20 _
_� $iqnatu'e M appliram drasa ol e00�ipnt (numbar aiM sboef. ci.y, slafe, aMl ZlP co0e)
/ �--�. � (� S� .3 S. ��D F l �
Signa�urB 018uthonzed represerMa�ive AdEresa of euthonzad rewesenWtive (numbofdM stiee( city, stafu, end Z/PCOtle) i% 7G �
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