Age_Watson;
o APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
�State Form d3708 (R919-OB)
•��• Prascn5ed by lhe DeGaM1ment of lxal Govemment Finance
Information matained in this tlocument is CONFIDENTIAL Oursuant to IC 6-1.7-72-9 antl IC 6-1.1-35-9.
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INSTRUCTIONS: v'( � ��J�
To be filed in person or by meil wrfh the CountyAudilor o! the county where fhe wooerry is locafed. o
Filirrg Dafes: iJ Real PropeRy: Ounng the hveNe (72J months be/o� December3l o/the yaarthe deduction is tolb sitecfne�UNTY AUDITOR
2/ Mobile Hanes assessed urxler IC 6-iJ-7 or manu7aciuretl bomes nof assessed as real property: Dunng Ne Iv+elve (72J montF,s
be/ae Marc�h 37 0/ the year fhe deduction is to 6e e/fective.
See reverse sitle for atldi6�one1 insWCtions a� qualifications.
Type o1 heneft reQUested (yoaso Mxk aH Nat epply)
� Over 65 Deduciion hom Assessed Valuation Over 65 Circuit Breaker Credit
Name af eppGCaM (ovrt� or ant+ecf DuyoQ /'�
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Is eoPlimm �he soie Iegal orequitabla owneR If No, what is hisllier exacl share or interast7 i( ownad vnth somaore olher than spouse.
indinte vntn wham
❑ Yes ❑ No
tl neme on recortl is diftarant Nan Pat d aod�canl ��Cicete bebw
Name of coniad sellar (applicanf must haro been ovyiry on cm'vact at least orie (1) yeaQ
Adtlrass ol mntrad saller (numbaan0 swel, ciy. sWlo. end Z/P code) Is the prooerty in puestion:
� Real propary � Mobile home (IC 6-7-7-�
� Wing disirict Key numaer / Legal descriotion I Record num5er Page number
- a(o-17 -/� -30� - �� s�. so8-o �,
Is Iha propeM u and occuGieC p' - br Assassed value of t"e prooerty as oi Ma¢h 1, cur.ert year (mny nof erceed 51ffi,d30
hiertier residen lor Owr 65 tlotluction, w S f 60.000 kr tho Over 65 Ciicuif &oako� Ciedi�
❑ Yes ❑ No
Waz the a00��wm 65 years of age w mora on Dacem6er 31 of the year Aoplimnfs data of oitih (month., day, yoarJ If filec by e surviving. un.�remed soouse,
oriar to me arrem yean
Have you fi�ed fw ar.y other EeEuctions? If Yas. wnat ceducnor.s?
� Yes � No
Have you fied for CeducGons in any other counry7 t/ 1gs, w:-at wunry?
� Yes ❑ No
IIWe certi(y under penalty of perjury that ihe above and foregoing information is true and correct and fhat the applicant was a resident
of Indiana and owner of the a(orementioned property on March t. 20 _
Signature of avp��car� deass ol ao0��nt (num0er ar,tl street. ciry. s:afe. antl ZIP code)
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ipnature W authonzed reo�sentatre PAdress ot autho�ized raoresentative (num er and 5treeC ciry, state, and ZIP c o)