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"' APPLICATION FOR SENIOR CITIZEN
5;:� PROPERTY TAX BENEFITS
� �,• State Form 43708 (R9/ 9-08)
Presai6ed 6y Uia Depnrtmerit of Local Govemmem F'u•.ance
Infortnation contained in ihis document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC Cr1.1-35-9.
COUNTY TOWNSHIP YEAR
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To be filed in persm or by meil witA the CountyAUdita of fhe county where the property is Ixeted. ��� �� Z O, O
Filirg Dales: 1J Real Property: Durirg fhe hveNe �12J marths 6e/ae Decem6er 37 o/fAe ysar the deduction is to be e
2) Mo6ile Homes essessed under IC bf.1-7 ormanulacfured homes rrot essesseU as real property: Dunrrg fhe rtveNe (72) months
belore March 31 0l the year fhe tleduction is to be eHeclive. �� i?/! _
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See reverse side 7a atlGitional insLUCtions a� qualificalions. ��
Type d beneEi repueat�
tl name on recortl Ls dilf
Nama of mntrsct seller
�lease d�eck Bll Na( apP�Y)
Over 65 Deduction from Assessed Valuation
shai
Yes ❑ No
n than that d epplimnl indicate bebw
Niwnf must fuvc Mon buying m canhact at bast orro (il yeaQ
of mntratl aaAer (number and sbeet tiy. safa,
Key number I Legal Eai
� -/� -� 9-
.__.._, .'_"'.._.
Yes ❑ No
Was l�e aoW�em 65 yean o( age or more on December 31 N the yaar
Dnor to t�e artertl yea(1 �y
Il(I Yes ❑ No
T'
Adjusted gross income of appliwnR spouse, and any
individuals sharing ownership (FOrOver 65 deduction, income
may not exceed 525,000; lor the Over 65 Circuit Breaker Credif,
income may rrot exceed 530,000 lor individuals, or 540,000 for
mamed couples).
Hava yw filed br any Wher deductiona?
Wer 65 Circuit Breaker Credit
tl owned with saneona Wher than spousa,
inEipte with whom
Is the pmoerry in cuestion:
Real property � Mobile home (IC 6-7-7-�
Record num6er Paga number
_ oo�• 35�3. ov �
'
❑Yas ❑No
Have you filed fw deductions in any mher coumy? If 1§s, wnat counry?
� Yes ❑ No
.
IIWe certify under penalty of perjury that the above and foregoing information is true and correct and that lhe applicant was a resident ;
of Indiana and owner of the aforementioned property on March 1, 20
�
Signature ot a00frant Pddrass ol applibr.t (nwnbw nntl sfieef. ciy, stafe, a�W ZIP cotle)
C �, � a�a5 S, 650 �. �rdnersco �/�1� �/76`f'
Signatu:a W aNhorizeE iep�asentativa Pddress of authonzad rarnasanta�ive (numboraM sbeof. ciry. sfalo. an0 ZIP coCe)