Age_GoeddeAPPLICATION FOR SENIOR CITIZEN couNn � TOWNSHIP � YEAR
,. Irt. 1 PROPERTY TAX BENEFITS
Sq1B Fortn 43708 (R9 / B-0B)
���u � Prescnbed by Me Department of Local Govemment Finance
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Informa:ion wntainetl in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC G1.13S9. , ,
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INSTRUCTIONS:
To be filed in persar or by mail wNA the CountyAudifor o7 the county where fhe properry is located. A P R 1 6 L U I U
Filing Datas: 1) Real Prz�peAy: Dunng the IweAre (12J months be%re Decembar 31 o/Ihe year tbe deducfion is to be e%ctNe.
2) Mobile Hames essessed urMer IC 6-7.7-7 ormanNacturetl homes rro! assessed as real pmpe rg Ure (72) months
6e(we March 31 0l Ne year fhe tleductlon is to 6e eflecfive. RU�
SeereversesidelaetltlaionalinslnictionsarrdqualificaGOns. OIBSO�OU�ITY AUDITOF
Type of henefit requestad (pease e0lhet apply)
Over 65 Deduction 6om Assessed Valuation er 65 Circuit Breaker Credil
Name of
H reme on record U diflaram lhan ihal d epolican4 �Mics�e 6ebw
Name of coni2a sel r/app7canl must hare Deen Duying m cmuact a� least orro (1) yearj
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Pdarass ot mn seller (numOm aMstreef, cily, sfato. antl ZIP mtle) Is tne orooerry in auesfion:
��I property � Mobile home (IC 6-74-n
Ta�� d'alnd Key num6er / Leqal descriotivn Record number Page numEar
c� G-d3-OS-aoo-ooa ��-oay
la pmpeM use0 end oau0ied primadly for AssesseE value a( the pmperty as ot March 1, current year (may rrol exceed 5182.430
his/her rasiEence7 for O�e� 65 deductim, a Sf60.000lor Ne Ovef 65 CiicaR Breeker Gedi�
Yes Q No
Was lhe eppliceM 65 years of age ar mora on DecemDer 31 of ihe year
Have you filed fw a�ry olher deEuttims4 I( Ves, wha� deductions7
� Yes No
Have you fJed fw deduclions in any dher cwrity7 If 14s, what counry?
� Yes �No
IM/e certify under penalty of peryury thal the above and foregoing information is true and correct and that the applicant was a resident
Pddrasa of eulhwized r presentative (numbar and s'voet. uty. stato. and LP code)
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