Age_Devischeybergen�
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APPLICATION FOR SENIOR CITIZEN
_- - : PROPERTY TAX BENEFITS
'S '' Slate Form 43708 (R9 / 9-08)
Prescnbed by Ihe Departmam of Lasl Go�ertmerit Finarice
Informalion conlained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC Fr1.1-359.
INSTRUCTIONS:
COUNN TOWNSHIP j \'
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To be filed in person or 6y mail with the CountyAuditor of the oounty where the property is located. ��� ��
Filing Dafes: 1) Real Pioperty: Dunng fhe fweNe (72) marths 6e/ore December 37 olthe ysar fhe deduction e H �2
2) Mobile Hanes assessed urnler IC G1.1-7 or manWactured homes rrot assessed as real pro� n e IweNe (72) monfhs
be/we Maich 37 0/ the year (he deduction is to 6e eflective.
Seereverseside7aradddionalinswclionsandqualifications � GIBS
TyOa d banaf.l reQUested (daase rlieck a0 Nat aPPM
� Over 65 Deduction hom Assessed Valuation �Over 65 Cirwit Breaker Credit
Is app6mr� Ihe .e legal or equitaWe wmeY/ If No, what is hislner eud shar¢ or imerest7 If ed with mmame othar than spwm,
in - e vAth whom
❑ Yes ❑ No
N name on recad is dMarem Ihan ihat of applicanL i�M'uste below
Name af arrtraG se0er (app�icanf must have been 6uy"u�g m cmbacf af lea5 orre (1J yearJ
AEdress d mntrad seller (nvmbar anC streeL �y, sfafe, erW ZIP codo) Is Iha pmperty in queslion:
�Real pmperty � Mobile hwne QC G74-�
Taxingdistrid Keynumher/LaqalEes�iption Recortlnumber Pa9enum6er
c�b-�o- �- - ,�".:__,
Is Ne pmperty used a acwOieE manty lor AssasseC val�e of Ihe prope�ty as ot Mamh 1, wrtent year (may rwt nxcmE E7H2.430
his�her �asiEanm7 !oi Oeer 65 dedudini, n E760,000 for the Over 65 Cwicait &ealmi GediQ
� Yes ❑ No
Was tha eppfxaM 65 years af age or more on December 31 of Ltie year li�ant's
Amount of Income
individuals sharing ownership (ForOver 65 deduction, income $
may not exceed 525, 000; for the Over 65 Circuit 82aker Credif,
income may nof exceed 830,000 tor individuals, or 540,000 for $
manied couples).
TOTAL $ 0.00
Have you Glad for aM a�er deductions? i( Ws. what ded�ctions7
� Yes � No �
Hava yau filed for deCuctions in any olher cwnry? If �§s, what coumy!
❑ Yes �.No
UWe certiry under penalty of perjury that the above and foregoing infortnation is true and coneci and thal lhe applicant was a resident
of Indiana and owner of the aforementioned propeAy on March 1, 20
Signaturedappfram AddrassafappfimM (mmberandsbeel,rily.sfafo.aritlZlPmde)
SipnaWfe d authortzed reprasantative Address of aNhor'rmd represeniative (numEeraMsheef, city, sta:n, and LP code)