Age_WhiteheadAPPLICATION FOR SENIOR CITIZEN
� , PROPERTY TAX BENEFITS
� ` ' Stafe Fortn 43708 (R9 / 9-OB)
Prascnbad by tha DepartmeM of Local Govemmem Finance
Infortnatam m�tained In ihis docvment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
wsrnucnoNS:
COUNTY TOWNSHIP � YEAR j
I
MQR 0 9 2p11
To 6e filed in person or 6y mail with fhe CourrtyAudita of Ne county whera the property is /ocated. C. �
Filing Dates: 1J Real Property: Durirg fhe AveNe (12) months before Decem6er 37 o/the year fhe deduction is to be e9ecfnre.
2) Mo6ile Homes assessed urMer IC 6-7. 7-7 or manufacturetl homes rro( essessed as real properf��Caa thB RveNe ) ths
(7N GOUNTy AUDITOR
be/we MarUr 37 07 fhe yeer the tletluction is fo be eHective.
See reverse sitle for aOtlitional insWCtions arM qualificetions.
TypB N benef.i reGUested eese thotlr a0 Naf epply)
Over 65 Ded�ction 6om Assessed Valuation Over 65 Circuit Breaker Credit
Nama of apWicam (owncr w confracf Euye�
Lq a p rrt lhe sde Iepal or epuitaMe owneY! If No, what u hiSRier ezaG share or irtlerest7 H owned wilh somaone dher than spouse.
intlicate with whom
❑ Yes ❑ No
tt name an record is diflerem Nan ihal of applican� i�icata belov:
Name of cont2d seAer (app(icant must hava Dewn Dtry'vg m cmvact at leasf orie (1) yea� �
Adtlreas ot mntrad eeAer (numba and shae4 ciry, sfam, aM ZIP cada) Is �h`e o�!aerty in Quesiion:
� , IX I Real pmperty � Mobile home (IC 6-74-�
�—'t
Tanin 'tnd Keynumher/lapeldascription RecoNnum6er PaganumGer
_
- /5 oa-a��.i,3�-aa
U Ne property used and accupieE pnmanty br Assessed value of the property as of March 1, ctinem year (may not exttrotl S1B2.d30
hivher residen�7 Por O�er 65 tletlartiar4 p S i60.000/oi Me Ovor 65 Limuk &eaker Credi�
❑ Yes ❑ No
Waa Ue appi'�m 65 yearn ol aga w mora on DecemCer 31 of the yeer
Have you filed for arry other deducCOns7 If lAs, what deductiona7
��, � Yes ❑ No
Mave you filed for deducGOru in any other cauMy9 If 1gs, whaf cour.ry? .
� Yes �No
IlWe certify under penalty ot perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 •
Sipnature W appliram Pddress of aoo���� (�wnber aM sbee(, ciry, sfale. eM ZIP coCO) _.
��-z,���..;��a�t,.�✓ z � �y � s� s. ��,� ° y��-�o
Sipnetura ot authonzed ra0�eser�tative AdErass of authonzad representative (numbaraM sLeef, ufy, stato. antl LP mEe)