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" APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
Stab Fortn 43708 (R9l 9-08)
� S y, '� PrescnbeE by Ma OeparLmeM of Local Govemmem Financa
Infwmation oontained in lhis tlocument is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 61.1-35-9.
COUNTY TOWNSHIP YEAR
� File Mark
INS7RUCT10NS: �,��� '
To be filed in person or by mail with the CountyAuditw of fhe county wbere the property is located.
Filirg Dales: 1) Real Property: Dunrg Ne fweNe (f 2) mrnths befoue Decem6er 37 o/fhe ysar tAe deductlon is �rg1�I{ �f '^,
2) Mo6ile Homes essessed ulMer IC 6-7.1-7 or manufaclured hames rrof assessed as real property: Dun�9ie4{��e (72) monfhs
6e(ore Mam/r 37 0l the year the deduction is to be eflective. C. �.
See reverse sitle /w adddional insWCfions a�M qualificetions.
Type o( Danef.t repuested (yease diack e0 fhaf appl� OUNTy q�p '�
�\ ITOR
Over 65 Deduction hom Assessed Valuation ❑ Over 65 Circuit Breaker Credit
Name d eodicarit (ohn�a� )a cmtiaaWye�
❑ Yes ❑ No I
tt name on racortl u diflerartl tlwn ihat of aDd'�canl iMicata bebw
�Tazing distrid
�
seAer (applicant must haw boon bvy'Irg on canLatt ef leest one (1) yeeh
eM strae4 c+y. smle, and Z/P code)
Key number I
� ll.U�-N%^'�- I u fl -o� t�
b ihe propeM used eM occupied primany lor
hiafiar rasidan�?
,� Yes ❑ No
Waa Ihe aOD�Kam 65 yeara of age or more on December 31 of the year
pnor to the wrtem yea(7 �-�(
❑[J Yes ❑ No
��
Adjusted gross income of applicanR spouse, and any
individuals sharing ownership (ForOver 65 deduction, income
may not exceed 525, 000; for the Over 65 Circuit Breaker Credif,
income may rrot exceed $30,000 for individuals, or 540, 000 for
married couples).
Have you (led fw airy Gher CeCUCUOnsT
❑ Yes
you filec fw daductions in any other courttyl
� Yes
� No
No
i swnaone aner inan spouse.
whom
Is 1he prOOeRy in puesiron:
� Real pmperry � Mobile home (IC 644-�
i Record numbar Page r.umce;
3c�-oa�.t� �o/
AssesseE value of ihe property as af March 7, cunent yaar (mayirot axceed 57ffi,d30
!or O�er 65 tletludion, a f f 60.000 Ior Na Over 65 Cirartf &oakor CrediQ
MD��nfs data ot birth (monlh, day, yoa�
��
�? � 5� �'r�. ,�.�/�' �'r�.l��,
of aultrorized ra0�esemativa (num0er a� sbeef, city, 9ato, and LP code)
re!. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
b-_.. PROPERTY TAX BENEFITS
S• State Form 43708(R10/12-08)
: � ' ,
r.,. Prescribed by the Department of Local Government Finance I + lm. .
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS: MAR 3 0 2016
To be(led in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the year the deduction is t. � w
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real meta !/Coil . • •, i6itWths
before March 31 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Type of benefit requested(please check all that apply)
❑I"fOver 65 Deduction from Assessed Valuation [Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
Veo qe L '11
If name on record is different than that of applicant,indicate below
Name of contract seller(applicant must have been buying on contract at least one(1)year)
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
a4,-a0 -iSc 10 co/
Is the property used and occupied primarily for Assessed value of the property as of March 1,current year(may not exceed 5182,430
his/her residence? for Over 65 deduction,or 5160,000 for the Over 65 Circuit Breaker Credit)
EP Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
_
Have you filed for deductions in any other county? If Yes,what county? •Q��fq`''
❑ Yes ❑ No fl
UWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
/ Address of authorized representative (number and street.city,state,and ZIP code)