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APPLICATION FOR SENIOR CITIZEN couNn TOWNSHIP rena
. PROPERTY TAX BENEFITS � �
State Fortn 43708 (R9 / 9-OB)
•� � Prasaibed by Ne DeparLmeM of Local Govammerit Finance
.'. F����2 8 2011
Informatiom m�tained in �his Cowment is CONFIDENTIAL pursuanl lo IC G7.1-12-9 and IC 61.1-35-9.
INSTRUCTIONS: C � �J. �
To be fi/etl in person or 6y mail with fhe CounryAUtlrtor of fhe wunty where fhe property is laca(ed. �
Filirq Dates: 1J Real Properly: Dunn9 fhe M1velve (72) mwMhs befrna December 37 0! the ysar the deduction is fo 6e el�j�ON COUN7Y
2J Mobife Hanes assessed urMer IC 61.1-7 or manufactured homes rrot assessed es real properry: Dunig the hrsha (72) monr%��DITOR
be(ora March 31 o/the yearthe deducbon is to 6e eflective.
See reverse side !or add"Aional insWciions arM qualfications.
Type d benef.t rapuesleO (ploase rhec4 a9 Naf aPyy�
�Over 65 Deduction 6om Assessed Valuation ❑ Over 65 Circuit Breaker Credit
Name d appGram (awrrer or cartract bvye�
lLi-y �
Ls appl'imM lhe sda legal or apuifable ameR tf No, what is hisRiar axact share w i�riarest7 H owned vrith mmeona other than spousa,
indimia vrith whom
❑ Yes ❑ Na
H eama on racord is ddferent Ihan tlul of applicant, iMicata bebw
Name of cont2d seller (appl'rcanf must have bo`n buying on cronfrdct af least orie (iJ yoah
Pddress d mntratl seliar (num6ar aM s6eeL �N, sta�, aM LP mdel Is Na P�PartY � Guestion:
�Real property � Mobile home (fC fif-l-n
Taring disirid ^ —_ Kay number / Legal Cescript''�j Recortl number Paga num6er
�� l0'�02 /9 /o�r - Q�° /1.t �'7
Is Ne propeM �� a`M occupied pnmarily br Pssessed value of the p(oPe`ty as ol March 7, wrteM year (may rwt exreatl 5782,430
hisRier resitlencel for O�er 65 dedudion, or Sf 60,000 /or Iho Ovr165 Ci�caif Brealmr Cred��
❑ Yes ❑ No
Was the app&a�n 65 years of epe a rtrora on Oecember 37 of Iha ywr
����
Yes No
Hava you filed tn deductions in any other counry7 It Yes, what munry7
� Yes ❑ No
VWe certify under penalty of perjury that the above and foregoing infortnation is We and covect and that ihe applicant was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20 _
Signalure d apd�m�� /Ja� Address of applksnl (numberarid soneL �y. sbfe, aiM ZIP wde)
,/ �� r �
l� ,t�-, , i /�/ c ,� OOS�
Signat/ura /oteuU�orizad raprasentaliva Pdtlress of authorimd representa�ive (manbrJ aM sLeof, cif}; state, anE LP crotle)
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