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�APPLICATION FOR SENIOR CITIZEN courm TOWNSHIP _ YEAR
PROPERTY TAX BENEFITS
State Form 43708 (R919-08) �
�O � Prescnbed by the DepartmeM of Local Govemme`rt Financa
ile Mark
Informatiom m�tained in this dowment is CONFIDENTIAL oursuant to IC Crt.1-12-9 antl IC 61.7-35�9.
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INS7RUCTlONS:
�l.l / 6 nr��
To be filed in persar or by mail with the CountyAudifw o! the munty where Ihe property is located. C�
Filing Dates: 7J Real PropeRy: Dunng the tweNe (12) montlts 6e/ore Decem6er 31 ollhe year the deduc6on rs to b�e t .
2)MobileHanesascessedunderlCbl.7-7o�manu7acturedhwnesrrofassessGIBSONI;UIJNQ�� �e��Z�months
6e/ore Marrh 37 0! Ihe year fhe de0uction is fo be efleclive.
See reverse side foradd�ional insVUdions arM qualifica6ms.
Type of beneft raduested (pdease d�eck aOlhat apply)
Q�er 65 Deduction from Assessed Valuation 1�-1i Over 65 Circuit Breaker Credit
Name o( xOP��� (owrier w canfratf GuYerJ
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Is appGcam the sda lepal or eqWtable rnme(1 If No, what is hisTher enar] share w i�ta(es17 It owned with someone other Ihan spouse,
indiote with whom
❑ Yes ❑ No
If reme on recad'o diftareM ihan that d apq'xanf, indiiate bebw
Name of conlrsd se0er (applxant must ha�e been b�ry'ug m cantract at leasf one (i) yea�
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Addrass of mntratl seller (numboranEStreo4 �+ty. sfale, and ZlPmde) �s �he p`opetty in Question:
Real property � Mobila home QC 674-n
,Tazing d'¢irict Key number I Legal desaiption Recmd number Paga number
�(� /$-33:3oo-ca���3la-od
Pe propery used afN occupiad pnmariy tor Assessed valua of Iha poperry as of March 1, wrtant year (may rrot e.rceed E782,430
is/her rasidanoa7 !or U.er 65 tletlucfion, ar E760,000 /orNO Over 65 Ciiciul &eaker Ged�
�Yes ❑ No
Was the appGCaen 65 yaars of ape or mwa on Decambar 37 of Lha year
Have you (Jed far deduc6ons in any mher munry7 If Yas, whal courrty7
❑ Yes ❑ No
IIWe certify under penalty of perjury that the above and foregoing information is true and correci and that the applicant was a resident
of Indiana and owner of the aforementioned property on March t, 20 _
Signalura d applicant Pddrass of apP��nt (numbcr and streef, dty, slafa, arM ZIP aodo)
, Gs., /oo4,S� S�f�' �Y FT fiP/�.�f%/.�/ 5�%(o f�B
Signatu authorizetl represeniative Address ot aNAw'rmtl repesentative (mvnbor rrd sLeeL �: stato, end LP cada)