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APPLICATION FOR SENIOR CITIZEN co T i renR
.,. -rt PROPERTY TAX BENEFITS �
y �; � Sfate Fortn d3708 (R919-08)
� u, Prescnbed by the DeGartment ot Local Govemmeni Finance
Infwmation con;ainetl in this doament is CONFIDENTIAL pursuant to IC 6-1.7-72-9 antl IC 6-1.b35-9. DE� ° I� �""�
INSTRUCTIONS: "y� ��
To be filed in person or by mail with the CountyAudita o7fhe muny where fAe property is locafstl. ✓��
Filirq Dates: 7) Real Property: Dunnq the fwelve (12) months before December 37 0! the year the deduclior���B�r�TY AUDITOR
2J Moblle Hanes assessed urrdei IC 6-7.1-7 or manufactured homes no1 essessed as real property: DuArg Ne twelve (72) months
6elore March 31 o/fhe year the deduclion is l0 6e eHective.
See reverse side fa adtldional insWdions and qualificetions.
Type W beneft repuasleC (deeso Weck a0 fhal apW�
�Over 65 Deduclion from Assessed Valuation � Over 65 Circuit Breaker Credit
Name of epo��ca�t (ownor n' cmfracl Duyo�
Is ao�li�ant �ha so!e leqal or eUUitabla owne(7 �f No, what is his/ner axact 9hare o: in�eres�? If ownad vnth someone other ihan spouse,
inditata wit� whom
❑ Yes ❑ No
It name on record is diflarem Ihan thai of aoDlkant indicate bebw
Name W contad sellar (epplicant musf have Eoan buyiig on conl2ct at laast orre (1) yearj
Address W contratl sePer (num0er erid sbeef, ciy, stata, arW Z/PCOde) �s �ne orooerty in cuestion:
� Real propery � Mobile home (IC 64-7-�
� T�ing d'utncl Key nomber I Legal deunOlion Reco�d rumber Pa9a number
z� -i3-<9-i�� �ovo.o o;oos�
Is the DropeM used and occupied wvnar.ly br hssessad value of t"a orooe:ty as of March 5, wrteri year (may nof exceod S:B2.a30
hisRier rasidenw? !or Owr 65 �oduc(ion. w 5:60.000 !or f�e Over 65 Giicuit &vaker CrtMi�
❑ Yes ❑ No
Was the aDd��165 years o( age w:nore on Oecember 3� W tne year
Have you (ied tor any other deductior.s? If Ves, a�hat ceductior.s?
�Yes �No
Have youlled tw detluctions in any dher muny? I �t Yas, wnat county?
� Yes ❑ No
INJe certify under penalty of perjury that the above and foregoing information is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
SignatureoteoP��wol PdEressofaDO�iqnt (numberandsvoat,ciry.sfata,andZlPmdo)
�, ,�..� sso 7 � . �s. �e � � � ,r,v �7 �s�
5' alu of aNhonzetl ra resentaVVa Adtlrass af authorizec reoresentative (numDerantl sbeet, ci.y, sfaro, and ZIP co0a)