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APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
� S.''• Sfate Fortn 437081R9/ 9-08)
� �. Prascnbed by Uie Departmem of Local Govemmem Finance
Infortnatiom m�tainetl in this Coament is CONFIDEN7IAL pursuant to IC 6-1J-72-9 and iC 6-1.1-359.
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TOWNSHIP YEAR j
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INSTRUCTIONS: ��yn� � �
7o be filetl in person or by mail with fhe CountyAuditw of Ne county where fhe property is locafetl.
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Filirg Dates: 1J Real Property: Duri�g fhe hveNe (72) mwrfhs be/ore Oecem6er 37 o/the ysar the deductioC*1S?@Qq.��i�TY AUDITOR
2) Mo6ile Homes assessed under IC 6-7J-7 or manufacturetl hwnes rrot assessed as real propeAy: Dunng fhe hveNe (72f monMs
6e/we Marrh 3 f o1 the year Ure deduction is fo 6e ef/ective.
See Ieverse sitle /or atld4ional inshudions arni qualificalims.
TYPe of ba�refit reauesteO (Woeso chock
owned vnih sameone othar than spouse.
indiote wit� wtwm
❑ Yes ❑ No
H name on remrtl is CifkreM Cun Ihat o( apd'ran� iMicata belrnv
Name d wnirad seller (applicanf must have baen buy'ug m conVaG et /oest one (7J yea�
Pddress of mntratl sa0er (numDw eM stroeC ciry, sbte. eM Z/P wde) Is lhe o�uerry in Question:
.� Real property ❑ MoDile home QC 6-14-�
Wing distnd Key number I Lepal desuiplion Record num6er Page number
210 -19. 3 a-/o� - ooa. a 3 s.oa �
�he propeM used and occupieE primariy br Assassed value of the proPerry as oi March 1, wmem year (may nof ercea0 StH2,a30
hisRier residence9 IorO�er 65 tlotludiar. ar 5760.000 /or Ne Owr 65 Circurt Breaker Getl��
,� Yes ❑ No
Was the eDW�wM 65 years ot ape w mora on DecemDer 31 of the year
Mave you filed fw airy ochar deEuctions9 I( Yas, v.�nat daduaions?
� ,�5 ❑ No �, S �
Have you �IaE lor ded�ctions in any other courrty? II T4s, whaf couniy?
� Yes ❑ No
IIWe certify under penalty of pe�ury that the above and foregoing informa[ion is lrue and cortect and that the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20
Sgna of applirsm /+ddeass of applimnf (numbor and sWO(, ciry, slate, mM ZIP mtle)
90 �. �• Sc.T %+oc./e^ Lt/ /y,v.�s�� Gtif'i�3
Signature G au�hwized reoresentative Address of authorized representa�ive (numberand sLeef, ciry, stafe, and LP co0o)