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APPLICATION FOR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
S "' Sqte Form 63708 (R9 / 9-08)
Piexnbed by the Daoanmenl of Loral Govemment Finanw
COUNTY TOWNSHIP � YEAR j
IMartnetiom m�faineC In Nis doamenl is CONFIDENTIAI. pursuant to IC 6-1.1-12-9 and IC 61.1-35-9. �����
INSTRUCTIONS:
To be filetl !n person or 6y mail with the CourAyAuCita o7 the wunry where fhe property is locafed. ^ D D �� Ol u
FAirg Dates: 1) Reel Property: Dunrg the hveNe (72J morrfhs befae Decem6er 37 07 the year the deduction irb da e ac
2) MoWle Homes assessed under IC 67.7-7 ormanufectured homes rrot assessed as �eal property: Dunng 7�e hveNe (72) monMs
be(ore March 37 0/ lhe year the deduction is to be eflecfive. "yn �+ ,{{/".
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See reverse side 7a adtldional insVUCtions e� queliflcafionx �j �
Type d banefi raQUested (please rheck e0 Nat epWy) �
Over 65 Deduction from Assessed Valuation CC i Over 65 Circuit Breaker Credit
(T
Name ot ap�licarit (owrror a cmhact evyerJ
[rViC_ �+- '
U apDlicam the sale lepal or eQUitaW eR if N is his/nar exad share w interest7 tl owned vmh someone oiher I�an spouse,
inditate with whom
❑ Yes ❑ No
If name an racord is diAerarn Man Mat d applicant, indicata belav
Name of cmtrzcl saller (appOCant must fwre Oean buyirg wn carC`act af least orro (1) yeuh
Addraes of mntrad eeller (numbcraM sbeef, ury, sfate, and Z/P cotla) Is ine v�oerty in Questian:
Real properry � Mobile home (IC 644-n
Wing disirict Key num6er / Le9al descriotion Record numhar Paga r.umber
_ �, U _ /�e�-oa
Is Vie O�M used and occuqed primarily br Assessed value of iha pmoerty as oi March 1, curtent year (may nol erceo0 5182.d30
hisfier (esiden�T !or O�ar 65 doduCion, a Sf 60.000 for Ne Ovei 65 Circuit Breaker Credi�
�Yes ❑ No
Waa lhe appl'�nI65 yean of eBa or more on December 31 of the year
Have you fded M a(ry othar datlucCOns7 If Yes, what detlucGOns?
❑ Yes ❑ No
Have you f9ed ta OeOucGons in any other wunry? I! Yas, whaf counry?
❑ Yes ❑ No
IIWe certify under penalty of perjury thal the above and foregoing information is Irue and correct and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Sipnetura d apo�icarit Address of ep0�itsnt (numbm arM sWat, ci.y, sfato, arM Z/P mde)
,B��G�. �. � o � s,,b P��a-.-� R� �... ���-�d� �., ��� 3
Siqnature Uauihorized resenW' Ad asa of euthorizad representative (numDeraM suoef, city, state, and LP code)