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�"' o APFLICATION FOR SENIOR CITIZEN
, E PROPERTY TAX BENEFITS
� � .. ' Stlta Fortn <3708 (R9I9-OB)
PeascnbaE by the Deoartment o( Local Govemmerit Financa
In`ormatiom m�tained in this tloaiment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 anC IC 6-7.1�35-9.
� COUNTY TOWNSHIP � YEAR j
I
File Mark
WSTRUCTIONS: � � � � �
To be filed in person or by mail with the CountyAUditor ol the county where the properry is located.
Filiry Dates: i) Real PropeRy: Dun�g the IweNe (12) months be/ore December 31 olfhe ysar 1he deduction rs to be �lCJe.9 O� n08
J U
2) Mobile Homes assessed under IC 6-7.7-7 ormanulacfured homes nof assessed as real property: Dunng Ihe twslve �� months
be(ore March 31 0! the year fhe deduction is to be eNecfive. ''y� �/
See raverse side la edUifional inswcfions arrd qualifications. �'/G� �/1<T
Type N benefi repueste (ploaso Mack aH Nat appin
If No, what is FJ eza
COUNTY
Over 65 Circuit Breaker Credi�
�/V � S
share w ir.terast? If o.vned with mmaona othe� ISan spouse.
Vf4�IfdIB Wll�1 WhO.T.
� Yes ❑ No I
If n3me on tecord i3 Eitferen� lhan �h21 Ot epplicanL ��diCdle bebw
Name ot mrtrsd sallar (applicant musf haw Doan Duyifg on ca:✓acf af least orie (1) yearj
Addrass ot oontraa
ciry, stafo, aM ZIP m0e)
��
Is Ihe �opeM used e� ottupieC pnmany for
his/ner reaidanw?
� Yes ❑ No
Was lhe aoo��wnt 65 yaars of age or more on December 31 of 16e year
�
wior to the artem yea(1
� Yes ❑ No
Adjusted gross income of applicant, spouse, and any
individuals sharing ownership (ForOver 65 deduction, income
may not exceed b25,000; /or the Over 65 Cirwif Breake� Credit,
income may not exceed 530,000 for individuals. or 540,000 for
married couples).
Mave you (ded tw a�ry o�her tledudions?
� Yes
Have you filec fw EaEUCUOns �n any Whar county7
� YCS
� No
� No
IS l!18 O�ODBff)' 10 QUBSliOf1:
� Real pmpery � Mobile home (IC 644-�
nion �) �]( /Record number Page number
�VV��. _"�/� �
lusessed value of the pmperry as of March 1, wrtert year (may not excecd 5182.d30
!or O�er 65 detluCion, or 5160.000 !or I�o Ovur 65 C'vcuii Bloaker Credi�
If Yes. what ceductior,s7
If W_s, wr.a� covn�y?
I/We certiTy under penalty of perjury Ihat the above and foregoing information is true and wrrecl and that the applicant was a resident
of Indiana and owner of the aforementioned prope�ty on March 1, 20 _ �
I rass ot aoolimrt (numba�and sviceq :i.y, stare. aM ZIP wEe)
�C1 �1� 5�as.f/�rsr� D�.(�i�,.: � C�, �, i.✓ �/�d! o
reoresentative . Address of au�horizac raorasentative (nvmborand sboet, ciry, 9atq and LP code)