Age_Burch. ,�
APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
� Stdte Form 43708 (R9 / 498)
� � � PrescribeE by Me Depanmem of Local Go�emmem Finance
Infwmatbn contained in this docvment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 anC IC 6-1.135-9.
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COUNTY P Y R
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Fi�B 6 2011
C.'J.n�
iNSrRUCnoNS:
To be filetl ln persm oi by mail wHh the CouMyAudRw o/ fhe county whera fhe property is located. p pg
Filirg Dates: 7) ReelProperty: Durhg fhe tweNe (12J marths be/ore Decem6er37 o7the yearfhe deducfion is to be eHe�CW�N COUNTY AUDITOR
2) Mobile Names essessed urMer IC &1.7-7 or manufactured homes rrot assessed as real properly: Dunrn� the twsNe (12) mmths
befae March 37 0/ Ne yeer the deduction is to 6e elfective.
See �averse sitle tor adddional insWdions eiM qualifications.
Type M benefit repuested (pleaso chock e0lhef apply�
,�Over 65 Dedoction from Assessed Valuation ,�Over 65 Circuit Breaker Credit
Nameo(ap m�m.,�era+�o�ye�
Is ao7�ip e ade lepal or ea eNe owne(1 H No, what is his/Aer exact ehare w intarasl7 H owned wilh someone other than spouse.
indimte vnth whom
❑ Yes ❑ No
M riame on record'u dCferam than Ihal d appGmn� ind'zate bebw
Name of comrad seller (appficant musf fave beon buyilg m conflact et least orre (f) yea�
Adtlress W mntrad w0er (nwnba aM straeL ciy, stafe, aM ZIP oo0e) �s lhe pmDerty in Questian:
�
(may rrof ercce0 S f BZ.a30
hivher residenw? toiO�er 65 0etlueim. a 3160.000 lor Ne Ova 65 Circuit Breakef Gedif)
�Yes ❑ No
Was �he applipm 65 years of age or rtara on December 31 d lhe year
Hava you filetl M arry olher deductims7 It Ws, what deductions? '
� Yes ❑ No � s /Y(-t �
Have you filed M deductions in any other counry? It l§s, wnat counry7
� Yes ❑ No
IIWe certify under penalty of perjury that lhe above and foregoing in(ormation is true and correct and that the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20
Signature da00GCam � � ACdress o(ao i�(�Or �strqy� tiN. sfafe. aM�ZlPcoda� j)�
3 � f� e� b s i�
�i��N � ro �t7� �d
Sign ure W auNOAZed reprasemaWe �lddress ot authaized re0�esaniative (n ber aM s✓ret, ciry, stafa, antl LP code)