Age_Hardiman (3)" APPLICATION FOR SENIOR CITIZEN o N ro u venFe
. PROPERTY TAX BENEFITS
�Stale Fortn 43708 (R9/ 9-0e)
�' �., � p(asaibed Ey Ihe Deparlmertl of Local Govemmem Financa
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Irrformation contained in this tlowment is CONFIDENTIAL pursuant to IC 6-7.1-12-9 anE IC 67.135-9.
INSTRUCTIONS: Q�(a�., ��
To be filed in person or by mail wBh the CountyAUdrtw o/ the wunty whera Ure property is located. G laG [�Nf�(1G��r,�
Filing Dates: 7) Real Property: Dunry tfre AveNe (12) months be/ore December 37 of fhe year tAe tleduction is COLe eRBCtN6TY AUDITOR
2) Mobile Homes essessed urMei IC 6-7. 7-7 or menu/acturetl homes rro( assessed as real property: Ounry t/ie tweNe (72) months
6e(ae Merc�r 37 0/ the yeer Ne deduction !s to be eflective.
See reverse side lor add �Aionel lnsWdions arM Qualifications.
Type o( ba�rof,t �epu e0 eate Mack e1 Naf appl� �
Over 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credit
Name af eCdimM (owner a canfiadWYeO
f � //�t '
Is apP��M Ne cole legal or eQUBaEIe awne(/ If No, whal ia his�her exact share or intarasl? H owned with �meone other lhan spouse,
indimte wilh whom
Yes ❑ No
rc name on racad Is aiHeiem tlian that d epofrant iMica2a bebw
Nama W mrrtad selier (xppl�canf must hava beon Duylrp on contfad et besf orre (i) yean
Pdd�ess of contrad se0er (numba aM s6eef, dry, sbfe. end ZIP wde) Is �he prooerty in auestion:
Real property � Mobile home (IC 6-14-�
� Tazi� disinct Key number I Legal escriotion Record number Page number
�-os-�s�o-ai/- c�� �4i o I7
Is tha o�GeM useE end ottupietl manly lor AssasseC value of iha prooerty as of March 1, wrteM yaar (may ml erceed 5182.d30
his/har �asidance7 !or Orer 65 dedudion, a t f 60.00O7or the Ovor 65 Circuif &oakor Crad��
�Yes ❑ No
Waz the applicant 65 years of age or mara on DecemDer 31 of tne year AOD�nfs da�e ot birth (monfh, Cay, yoar) If fJed by a surirving, un.mamec soouse.
prior to Ihe arreM yea�l what was tha spouse's age at lhe Ume
Yes ❑ No otd�m?
Adjusted gross income of applicant, spouse, and any
Have yau filed fur a�ry other datluctiona7 �� Wa. what deducUOns1
❑ Yes ❑ No
Hava you filed Iw deduc0ons in any dher wunty7 If t§s, what coumy?
❑ Yes ❑ No '
IIWe certify under penalty of perjury that the above and foregoing information is true and correcl and that the applicant was a resident
of Indiana and owne� of the aforementioned property on March 1, 20 _ , '
$gnatura af aod'�wM AEO�ass of eppli�nt (numba aM sboot, ciry, slate, a�M Z/P ooda)
� � ' o - N
Signatura W eulhoAzed reprasentative Addrasa ot authwized reDresentative (numDOrarM sbee4 ury, stato, and LP code)
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