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�'"' APPLICATION FOR SENIOR CITIZEN
r... 1 PROPERTY TAX BENEFITS
StalB Form 43708 (R9 / 9-08)
�' u�. � P(escnbed by Me Depanment ot Local Goremmem Finance
Infortnation wntalned in this doament is CONFIDENTIAL pursuant to IC 6-1 J-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
COUNTY TOWNSHIP � YEAR
File Mark
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To be filetl in person or by mail wrfh fhe CountyAUditw o1 the oounry where fhe properry is located. 1
Filing Dates: 1) Real Property: Durirg the fweNe (72) mmfAS 6e/we December 37 o/the year fhe deduction is to be ��) 20� 1
2) Mo6ile Hanes assessed under IC 51.7-7 ormanu/actured homes rrof assessed as real property: Duri�g the fweNe (72) months
be/ore Ma�ch 37 olthe yeer the deduction is fo be eNecfive. C.`J.��`\-{
See reverse stle lar edditionel insWCfions aM qual"dications. V v
Type d baneft rapuesled (pi diock e➢ Nat apW�
Over 65 Deduction from Assessed Valuafion Over 65 Circuii Breaker Credit
Name of ap �' nt (ownB/ a canhacY EuyBQ
Is aoo���<<he sde lepal or eCUitaNe wmer) If No. what u his z d ahare w intere517 If owned vnlh someone ather ihan spouse.
indirate with wtiom
es ❑ No
tl name on ramrd is diflereM Nan Nal o( appfxant, indiceta hebw '
Name N crmt2d saAer (app'manf mus! have Deon buyirg m canhaG at bast orp (1J yeaQ
Pddress af mntratl satler (numba a� sbae4 cdy, sfale, aM ZIPwOe) �s tha D�oDerty in pues(ron:
� Real property � Mobile home (IC 6-1-1-n
Wing dlsincl Key numbar I Leyal Oescnption Record number Page rumber
� - - 3- ao-
Is the proparry useO aM oiee primany tor Assassed value of the o�oDarty as ol March 7, wr, en� yaar (may na exttrotl 5182.<30
his/ner rasidanw7 (or O�.er 65 tletlucfim. or S f60.000 for tAe Ovoi 65 C'ucuif Breaker CrtN��
❑ Yes ❑ No
Was che aON�M 65 yaen al age or moia on December 31 of the year
Hava you filed 1w arry other deductims7 �t 1§s, what deductions7
�Yes ❑No
Have you filed fu deOudion+ in eny otMr cwMy7 If 1§s, what coumy?
� Yes ❑ No
I/We certify under penalty of perjury lhat the above and foregoing information is true and correct and lhat the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20
Signature d eoP�'�M ndaresa or aooi+m�+ lnumber and strvef, cly, sfate, aM ZIP mde)
Si tu�e of auNOrized repraaamaWe Addrass of auttarized reprasantative (numbefand slreet ciry, sfate, and LPcode)