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,.-rto APPLICATION FOR SENIOR CITIZEN
: e PROPERTY TAX BENEFITS
State Form 43708 (R9l 9-08)
� ,' /
PrascnbeE by the Dapartment of local Govemmerit Fi: a:�ce
Information contained in this dowment is CONFIDENTIAL pursuani ro IC 6-1J-t2-9 and IC 6-1J35-9.
COUNTY � TOWNSHIP � YEAR j
File Mark
INSTRUCTIONS: � �-�/ � �
To be filed in person or by mail wrth Ihe CountyAudifor o1 the county wbere the property is located.
Filing Dates: i) Real Property: Dunrig the tweNe (12) months 6e/ore December 37 olfhe year fhe deducfion is to be �c�ive'� ��(j(j Q y
2) Mobile Homes assessed under /C 64. 7-7 or manu/actured homes not assessed as real pmperty: Dunng Ihe hvelve (i2%}(ionfhs
before Mardr 37 ot the year fhe deduction is to be ellecfive. �j�
See reverse s/Oe fw additional inshudions arM qualifications. ✓"� 4'^, ��
�ueslaE (p� asa Meck a0 W t appy) "•""`�" �-
�Over 65 Deduction 6om Assessed Valuation �Over 65 Circuit Breaker Credit
Name ot applirarif (vw+nv w cm✓ect Duyeh
� �
Is ao0licarh lha sale legal or puitable owneR �t No, whet
❑ Yes ❑ No
It name m recoN is diflarent Ihan that W aodkant, i(Micata bebw
exatl share or interast? If owneE with someone o�her Ihan spouse,
indipte wilh whom
sellar (applicanf must have Deon buying on conVatt ai loa5 orro
Address of mntratl setler (number
Tazing
I5 Lhe p�oOeM u5ec and occu0ied primanly br
hiSTar rasiCenia7
and ZIP mde) is the orooeM in QuesLOn: '
� Real property � Mobile home (IC 644-n
Key number / Legal descno��on I Record num6er Page r.umoer
a�-�9-i9 -�o/-DOO, ssoio a-�
IAsseued value of L`.e omoeny as of March 5, wrtent year (may rrot ercceG 5192.d30
1or Ow� 65 dcduCion, w 5 t60.000 b� Ino Ovcr 65 Circui: E2akn C2di�
� Yes ❑ No
YJas tha apd�m 65 years of age w mwa on December 31 of ine yea:
onor to Iha areent yeaY!
� Yes ❑ No
Adjusted gross income of appliwnt, spouse, and any
individuals sharing ownership (FOr Over 65 deduction, income
may nof exceed 525,000; fo� the Over 65 Circuit B2aker Credif.
income may rrot exceed 530,000 /or individuals, or 540,000 for
mairied couples).
Hava you fied tor ar,y other deduciiors7
� No
Have you flad tw deEuctions in xny other counry?
� Yes ❑ No
VWe certify under penalty of perjury that Ihe above and foregoing information is true and correct and that the applicant was a resident
ot Indiana and owner of the aforementioned property on March 7, 20 _
an re ot pGram �� n � PdCress of ap0licant (numeerantl streeC c�y, state. aM ZIP mtla)
So3 �. w1uG�
Address of authorized reD�esentative
state. and ZIP code)
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