Age_Sokeland� APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
State Fwm a3708 (R919-OB)
` e � Prascnhed by Ne Departmerit of Local Go�emmem Finance
COUNTY TOWNSHIP � YEAR
Fila Mark
Informatiom m�tainad in Ihis document is CONFIDENTtAL pursuant to IC 6-1.1-12-9 and IC 61.1-35-9.
INSTRUCTIONS: � � � � �
To be �led in person or by mail with the CountyAuddw ol Ne county wAere the property is located. ���
Fiiing Da(es: 1) Real Pioperty: Dunrg lhe AveNe (f 2) marths before December 37 0/ fhe year fhe d uchon is to be effectrvs.n'n
2J Mo6ile Hanes ascessed urMer IC 6-7. iJ ormanulacturetl hemes irof assessed as rea/ pmpb(Q'."�uaidThq�jy�e (12J months
be/ore Maid+ 37 0/ fhe year the deduc6on is to be e/fective.
Ul, l�''
See reverse side Iw a0ddional InsWtYions and pualificafions. �,i
Type of benafl reCUestetl �plea5 k eB Nat app�
Over 65 Deduction from Assessed Valuation ver 65
af aO�I'xart (owrier m cmhacf Duyad
b BDOIKarM the Sole lepal
H name on reco�tl b d11er
Name d mMad
Addresa ot
�
whafis hisRierd[actshare or
� Yes ❑ No
�M Man Ihat d applicanl in�
(evorKent mvst nave eear euyirp a, cmtraa at mast o�m (9 rae0
cily, sble, aM ZIP wOe)
N owned with sameme ot�er Ihan spouse.
indimte wilh wtwm
✓
�Real propetty ❑ Mobile home (IC 6J-7-�
Tazinp disirid Key number I Legal deacriotion Record number Paga number
o� f�if a�� a�1 ��� 3�=a�:o��o-�
�s we o�ceM used ene occupea cnmariy �or AssasseO value of the WopeM as of March 1, artem year (may rmt ercced 5182,d30
hia/ner ras'deno9 �or 0`er 65 tleLUCtion, ar E760.O00 /or No Ovor 65 Circuif &eaker CreOi�
�Yes ❑ No
Waa the a0��m 65 yeara of ape or mwa on December 31 ot ihe year AoO���
UWe ceAi(y under penaity of perjury that the above and foregoing infortnation is true and correct and Ihat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 �
Signelure ot
Address ol ap0����� (��mbw niM sbeaf, ciy. slato, aM ZIP mda)
y. H�,C�a,e�a r �i• iaKff�
re��aaentative (numborarW s:ivef, ciry, sfate, and Z/PcoCe)