Age_Clark�.
�
APPLICATION FOR SENIOR CITIZEN
R, ? PROPERTY TAX BENEFITS
, '' State Fwm d3708 (R919-OB)
� � i Prescn6ed by the Departmerit of Local GovemmeM Finance
Informetiom m�tainetl In this Cowment is CONFIDEN7IAL pursuant to IC 6-1.1-72-9 and IC 61.135-9.
C:�
�
INSTRUCTIONS:
COUNTY TOWNSHIP � YEAR j
I
APR 5 2011
To be fr1eC In person or by mail with Ure CountyAuditor o/ the county where fhe property is locafetl. C. �,
Filiig Dafes: 7) Real Prtperty: Dun� f6e fweNe (12) mmths 6e/we December 31 o/tAe year the deduction !s fo be eNective. n1��
2) Mobile Hanes assessed urMer IC 6-1.1-7 ormanulacfured homes not assessed es real prope�� 1 m s
�� Y AUDITOR
be/ore MarM 31 of Ne year the deduction is to 6e eRecWe.
See ieverse side ftr edddional insWCtions aM pualificetions.
TYDe of beneN reaua4ed Wease Medc a➢NataPM9
� Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
orrren tl N is his�Ter ezad share w irtteresl? tl owned with smneone other than spouse.
indimte wi�� whom
❑ Yes ❑ No
tl name on recortl is diflareM Ihan Ihat o1 epdicant inEkate below
Name of contract seDer (applicanf mtttt have been buyirp on cmbact at lea5 orre (1) yeerj
Address of mntrad seller (numOOrenO abeaC ciy, sbM, eM ZIPCOOe) I5 the proPefty in uuestbn:
� Real pmperty � Mobile home (IC 644-�
Taxirp olatnct Key numher / Legal tlescriDiim Record number Page number
b -ll-/7-5wo-000. 17i•ox/
Is �he propeM ed and ocw pnmanly (or Assassed value ot the Drooerty as ot Marth t, wRem year (may �rof ercee0 S 181 a30
his/her reside w7 �or Orer 65 CoCUrlim. d 5760.000 Iai No Ovcr 65 Circuit &eaker Crediq
�Yes ❑ No
VJaa lha aoW��165 years of ege w more on December 31 ot iha year
Nave you �led fiw a,ry o1he� deductions7 �t `es, wnat deductions?
�S ❑ No H 5
Hava you �IeO M deducUons in eny olher courrty? If }§s, what wunry?
� Yes ❑ No
IIWe certify under penalty of peryury thal the above and foregoing information is We and correct and that the applicaN was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20
Signelure of apD��i Addmss of eOP��M (number antl stroel, cify, sta[e, and ZIP potle)
� '3 g ,� .� ' - ' t
Sgnalure of aNhor¢ed iapreseMative Address of eNhwizeE reDresentative (numDaraM sueat. city, sfato, and L➢cotla)