Age_KargesAPPLICATION FOR SENIOR CITIZEN WN �q ^R
-. PROPERTY TAX BENEFITS a �
� ` ''� Slate Fortn 43708 (R9/ 9-081 .�.
PresuibeE by iha DepartmaM ot Local Govemmem Finance
Information oontained in lhis tlocvment is CONFIDENTIAL pursuanl to IC 6-1.7-12-9 and IC 6-1.1-35-9. Ma{��� ��
INSTRUCTIONS: :/J7 �Q
To be filedln persm a by mail witA Ure GountyAuditor o/ the oounty where fhe property is located. �� ��
Filinq Dates: 7J Real Property: Durirg fhe tweNe (72) marths befpe Decem6er 31 o/the ysar the tletluctlon is t�pg$QDNiC30UNTY AUDITOR
2J Mo6ile Hpmes essessetl urMer IC b7.1-7 or manufectured hanes rrot assessed as reel property: During the hvaNe (72) monMs
be/ore Mardr 31 07 the yeer the deduclion is fo 6e e/fective.
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See rererse side fa atltldionel insLUCtions e�M qualifications.
TypB d bBnef.l RpuaSed (pleese rheck a6 Nat epyy)
�Over 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credit
Name of apolicaM (owner ar cmhact buye�
�
U eD7�kam the sda iepal ar uitable owneR It No, what ia hislhar exacl share w mterest? H wmed with mmeone oihar than sowse,
indicate with whom
❑ Yes ❑ No
M nama on recoid "o diRareM Nan that a(applicant inCicata bebw
Name ot wrtt2ct seller (appficant musf Aare beon Duying m carrtract at leasf arre (1) yearj
AOCrass of contrad mller (numbw aM sbaeS city. sfafe, arN ZIP wde) �s ihe o�oa�ty in Guestion:
� Real properry ❑ Mobile home (IC 6-7-1-�
Tazin EisteiU Key number / Legal dascnptiw+ Record numDer Page rumeer
6 -d3 -lb'-3DO - oa0. sr3 -oa y
I e pmoeM1y used and accupiad pnmariry br 0.ssessed valua ot lhe DroDeM as ot Memh 1, wrter:t yaar (may rrof orceed 5182.d30
his�Ter rasidenm? br Owr 65 deduGion. a 5760,000lor No Ovor 65 C'ucuif &eakor Credi�
�Yes ❑ No
Nas l�e aooM1�M 65 yeern of age or rtrore on December 31 of tha year
Nave you filed tor aery olhx dad�ctions7 �1 �§s, whal deductions7
,�s ❑ No _ S
Have you fiied (or tleductions in eny other cwrity? It rea, what counTy4
� Yes ❑ No
IIWe certify under penalty of perjury that the above and foregoing information is true and correct and thal the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1. 20
Sipnature d applipm PdO�eu of applimnt (numberentl stree(, ciry, sfafe, aiM ZIP code) � �
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