Age_SchneiderAPPLICATION FOR SENIOR CITIZEN couN r+sH veaa
- . PROPERTY TAX BENEFITS �
'� ` I -'' Sfate Fortn 43708 (R9 / 40B)
Prascnbad by the Departmeril ot Local Govemmarrt Finance
In`ormation coniainetl in Nis tloament is CONFIDENTIAL pursuant to IC 6-1.1-12-9 antl IC Et.t-35-9. �kCo��
C.S.�
�NSrrrucnoNS:
To be filed in person or 6y mail with Ure CountyAudifw o/ the county where the property is located. gn �r
Filiry Dales: 7) Reel P�operty: Dunrg the hveNe (12J months 6e/oie Decem6er 31 0( Iha yea� the tleduction is to 6'eBe�cIiV60UNTy qUD170R
2) Mobrla Hames assessed urrder IC 6-7.7-7 ormanNactured homes rrot assessed es real property: Dunrg the tweNe (72) months
be/ae March 37 0/ tAe year the deduction is to be eflective.
See reverse side /w adddional insUUdions end quelifications.
TypB of bene£t repuepeC (pluase dieck a0 Net Bpp�y)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credil
Nama ol aDO�cam ( a cmhact DuyeQ �
n ` �J �
L
(� �
la a00����1 sWa iepal oraa ' e owne(1 � O, Wh21 i9 ht9/OB� B%dd Shd�B W iO19I8517 It wmed with someana olher than soouse,
indi Wte with wtrom
Yes ❑ No
If reme on record is d'MereM Nan thal of appGmnt iMicate beba
Name ot corrt2d seiler (applicant musf hare Oeon Duying an cmMact af laasf orre (1J yera�
MCreas d wr.trad eetler (numEer aM sboe4 cdy, stefa. aiH ZIP ooOe) 19 the D�Periy in aue5l'an:
�Real property � Mobile home (IC 67-7-�
/�'
Taxing disind Kay number / Lapal desuiption RecoN number Page num6er
��� o? - - QO - . 9� _ a�S
Lv Ihe o�DeM used anE D�ed P���H �� Asse55eO value of the poparty as of March 1, wRaM year (may rrof exmed S f82.d30
his/Aer residancs7 for Owr 65 deduGbn. a 5160.000 /ur Ne Ww 65 Circtirl Breaker Gadin
❑ Yes ❑ No
Was the epWicaM 65 yearo of aga or rtrore on December 31 of the year
Hava yw fileC for arry dher deEuctions? If Yaa, w�hat deductionst
❑ Yes ❑ Na �'/. ryJ .
Hava you filed for deduclions in any Mher coumyl If 18s, whal counry?
� Yes ❑ No
IIWe certify under penalty of pe�ury that lhe above and foregoing information is lrue and correct and lhat tha applicant was a residenf
of Indiana and owner of the aforeme�tioned property on March 1, 20 _ �,. �
Sipneture of appikam MERSS of appliont (numbwand sbooG city. sfafo. a� ZIP code) ��� � p
l� ,,���!!��, q�f g° s i So � 3� ,�^-����'� a
� Siqnatura authoriz O�seMative AEtlrass of aulhorized rewesentative (numberaM s'veet, ciry, s(ato, end LPCOOe)
1