Age_WorkmanAPPLICATION FOR SENIOR CITIZEN couNn rowNSHiv r�
PROPERTY TAX BENEFITS �"1, •
" State Fartn 43708 (R9 / 408) �
•� � Prescribed by the Departmenf of Loral Govemmem Finanw
� 1•'• F'�Q ark
Irfiwmation contained in this daamenl is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 61.135-9. M�R � Z��Z
INSTRUCTIONS C . `J. �
To be !!ed in person o� 6y mail with fhe CounlyAudifor o1 the county where the property is located. �
Filing Dates: f) Real Property.� Dunng the fwelve (12) months bafore Decem6er 37 of fhe yearfhe detluction is to (�e ��.COUNTY AU�ITOR
2) Mobile Hanes assessed urnler IC fi7.7-7 or manNactured homes rrof assessed as real property: Dunrg the hrslve (12) mm s
6efae Merrh 37 of the year the tleduction is fo be efiactive. �
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See revarse sitle (w addifionel instrudions arM qualiAcstians
Type W baneft raquested �tloasa Mack aD Ihaf apply)
Ove� 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name af epp6mnt (o.mrror cartrdct Evye�
� 0��
Is a P nf tha sde al ar equitaWa o-xneR I( No, what is his/her exacl share or interesl? If owned with somaone other ihan spouse,
indirate with whom
❑ Yes ❑ No
If �wne on iamfd is diHerent Nan that N appfimnt, intlicate bebx
IJame m mn�aa seuer (appLCanl m�ttf nare eeen nuy'ug «� cartraa al aast olre f�l r�
PdEress d mntrad salter (n�mG�r aM sbeef, city, stale, and LP coao) �s lhe pmparty in quesiion:
Real property � Mobile home QC 6-74-n
Tayu�g C"¢triq Kay number/ Legal dasrliption Remrtl numbar Page number
C�-� •,C � � - -�d - Ud.� �OU. �5.3- Did
Is the O�M used atM oavpieE primariy for Hssessed valua o( tha propefty as af March 7, wnent yaar (may rwt exceed f782,430
hivher residenca7 !or Uer 65 dedudim, or 5160.000 br Iho Over 65 Ci�cuit &ealwsCied�()
❑ Yes ❑ No
Was Ihe sppGraM fi5 years of epe or more on Oecember 31 of Ihe year AppGmnfs date ot b'uth (morkh, Cay, yaer) I( fJad by a surviwig, un�rrieE spouse,
o�r �o ma a,rrem y�n what v.as Ne spoum's age at ihe tima
� Yes ❑ No 7 otdeam7
Adjusted gross income of appliwnf, spouse, and any
rf�a yw ruee �or am omar aaa�:? u�, wrw� `daa��a
�Yes ❑ No %7 J.
Havayou fJeC for deductions in any dher cwnry7 tt Ws, what munry7
❑ Yes ❑ No
IANe certify under penaliy of perjury that the above and foregoing infortnation is We and cortecl and that the applicant was a resident
of Indiana and owner of the aforemenlioned property on March 7, 20
Signature d appfcar� PdCrass of applimnt (numbeantl stroof, cr(y, sfate, aM ZIP wde)
X..Si � - 7.sE. � . s��� � �
5' ure d or¢etl represeMative Pddrass o(author'rmd reprasentativa (numEwand streeL u7: ��e. �+0 LPcode)