Age_Akersi�
"' APPLICATION FOR SENIOR CITIZEN couNrr TOWNSHIP � YEAR
• . � PROPERTY TAX BENEFITS �
State Form 43708 (R9 / 4-08)
� u,• � prescnbad by U�e Oeoartment of Local GovemmeM Finance
i k
Infomiatiw� wntained in Nis Cowment is CONFIDENTIAL pursuani to IC G7.L12-9 and IC 61.735-9.
FEB 2 5 2009
iNSrRUCnorvs:
To be fi/etl in persm or 6y mail with fhe CounryAUditw of fhe munry where the property is locafed.
Filirg Dafes: 1J Real Property: Dunng fhe tweNe (72) mrntAs be/we December 31 o/lhe year fhe deducfion is to b�e%�i.,Q','(`����
2) Mobile Hanes assessed urMer IC Cri.1-7 or manu/ectured hames rrof assessed as real prone[hc Ounrgo � A�(?DITOR s
(iIt3SON (; U
be/are March 37 0! the year fhe deduction is to be e/lective.
See reverse side !or edddionel instructions erM qualificalions.
Type of heneft rapuested (please d�eck eH Nef apply)
� Over 65 Deduclion from Assessed Valuafion Over 65 Circuit Breaker Credit
Name ovr�m(aM,rerdcmhauoo I �/ � " �) ���� � \
t..li � � l.ciY � (/� � � " (,i ,9 A A %
� �+
Is aoo uar�t ihe sde lepal or eQUitade owneR If N0, whet i9 �i5/her exact ehare or in�BR517 H owned vnih someone olher than spouse.
indimte vnth whom
❑ Yas ❑ No
M name on rawrd ia dilfe�ant Nan lhat d eppli�n� indicete Debw
Name of comrsa se0er (appliwnt mus( haw Doon Ouyinp m confratt af loast orro (1) yea�
� Address af mntrad saller (numboreM sbeeG uy. atele, erW ZIP oode) �s tne prooerty in Queslian:
� Real pmperry � Mobile home (IC 61-7-�
Taving district Key numbar / Lagal description Record number Paga r.umber
Ce,r,�r� d� -/�-a8-3oo - D�l. 4�� -�05�
Is the pmoerty useG anE occuped pnmariy for Assessed valua of lhe omCeM as of Ma¢h 1, cuner.t year (may na oxccetl 51B2.a30
hisRier resWenm7 loi O�er 65 dotluctian, or St60,000 !or Ne O�m165 Circuil &oakor Credi�
❑ Ye5 o No
Was tha applicam 65 years of ape w mora on DecemCer 31 W Ne year AOU�icant's dale of bitlh (monN, day, year) I( f!ec by a survning, un.mamed soousa.
prior to �he artam yeaY! wtiat was the spouse's aBa at Ne time
JJ�--wS ❑ No �, — o�d��,z
Adjusted gross ineome of appliwnt, spouse, and any
Mave you filed for arry dher OeEuctions? It Ves. what deductions?
� Ye5 ❑ No � S _ .
� Have you Ned M deductioru in eny other courrty7 If �§s, what couMyi
❑ Yes ❑ No
tlWe certiry under penalty of perjury that tha above and foregoing information is true and cortect and that the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signetura of applicarM1 Mdrase of epPll�nt (num6erentl street, city, state, arM ZIPtoOe)
/� �-'�-�..c-Q�rn-.,� Z. 3 a o 8 S c- �. So Lz � c, c, 1• ' (�' y
Signatura of euthonzed ra0�esemawe Addresa ot authwized rao�ese�ta�ive (numberaM sneef, city, sta:e, and LP co0e) _
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