Age_JonesAPPLICATION FOR SENIOR CITIZEN
� PROPERTY TAX BENEFITS
S -; State Fwm 43708 (R9/408)
� Piescnbed by �he DepaNnenl of Local GovemmeM Financa
Infwmatbn wntained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 61.1-35-9.
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INSTRUCTIONS: 1I
To 6e /i7ed in person or by meil with Ure CountyAUdifor o/ the munry where tl�e property is located `lV L 6 200n
Filing Dates: 1) Reel PiopeAy Dun�g the Iwehre (12) marths 6efrne December 31 of the year the deduction is to be effecfive. �
2J Mobile Homes assessed urrder IC 6-1.1-7 ormanufectured homes not assessed as reai property: Dufitx7 the hveNe (72) mmths
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befwe March 37 of the year the tleduction is to 6e eBec6ve.
Cm.e eiMnlniuMM%innalineln��inneanrin�raliF�nlinnc GIB.SUN1�/ll��. _
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Type of 6enefit repuested (please rheck e9 Nat apply)
� Over 65 Deduction from Assessed Valuafion �Over 65 Circuit Breaker Credit
Name of apa���M (owner a cmt2cl
exad share nterest? H owned with wmeone other Ihan spouse.
indica�e wi�h whom
es ❑ No
It reme on reco(d is diReram Man that of applicant, indicata balow
Name of conirzcl seller (apd�nt must hare been buying on cmfraa
Pdtlress of mntratl sa�er (numbora�Asbaeq cify, sWte, aM ZIP mde) Is ihe o�ooerty in Question:
Real property � Mobile home (IC 644-�
T�'ug dislrict , Key num6er / Legal description Record number Page number
.'/67-
Is the p�opeM uSeO a�k occupied pnmanly for ' hssessed value of Ihe p(opefty as of March 1, curteM year (may not exceatl 5182,630
hisRier rasbence? Po/ O�er 65 tletlucfion, or 5160.000 !or Na Over 65 Circwl Breaker Credi�
❑ Yes ❑ No
Waz �ha applica�rt 65 years of eqe or rtrae on December 37 of Iha year
Have you filad for any other deductions7 If 1§s, what daEucliorsl
� Yes � No
Have you filed for detluciions in any other county7 ��'�es, what cwirty?
❑ Yes �Mo
I/We certify under penalty of perjury thal the above and foregoing infortnation is true and correct and that the applicant was a residen!
of Indiana and owner of the aforementioned property on March 1, 20
se�emre a aad�m Addrass of appliw�rt (number and sbeet, cily, ilate, anE ZIP mde)
(��� �, k83�os s�o�J � ��:..,s��. �� rt/Y7�bs
SignaWra of aNhorized representaGv � Pddrass of aWhonzad reprasen�ative (numberarM sveef, ciry, sfate, and LPcode)
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