Age_Springer� APPLICATION FOR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
S �' State Fortn 43708 (R9 / 9-08)
� PresuiCed Ey Me Depnnmanl of Locel Go`emmem Finance
Infwmatbn wntained in this dowment is CONFIDENTIAL pursuaN to IC 6-1.1-12-9 and IC G1.L3S9.
COUNTY TOWNSHIP I Y� I
File Mark
aa-��
INS7RUCTIONS: t '
To 6e filed in person or by mail wilh the CourrtyAudita o! Ne county where fhe property is locafed.
Filing Dates: 7) Reel PropeRy: Dunnq the fweNe (12) mwrths be/ore Decembar 37 0/ the ysar the deduction is to be eHective.
2) Mobile Hanes assessed urrder IC &1.7-7 wmanNacfured homes rrot essessed as real properfy.� Dunrg the (wslve (72) months
be/ae Ma� 31 0l the year the deduction is to be eflectivs.
See reverse side !or adddional insWCtions and qualificsfions.
Type d benefJ �ueated (ydeate Mxk e0 fhat apply)
� Over 65 Deduction from Assessed Valuation
Name ot a0�cant foM+�e/ or wnhacl DuyeO
!n/� i
( // V/LI.Y(�/ / /�1 �
is aoo�imo(the sWa leqal or epuitaMe own R Na, what is hisRier ezacl share
❑ Yes ❑ No
name on
Name d comract se�er (apyicant must hava been buyirg on cmhaci at �east ono (7) yea�
�� resa of contrad sa0er (numbw ard sbaet �Y. sbte.
�
�
eM occuPed O�m:M' br
� Over 65 Circuit Breaker Credit
legaldescnption �v. Oa�
i4/o3 �.
❑ Yes ❑ No
Waz iha applicant fi5 years of age a rtrore on December 31 W the year
o�� �o a+e a,rtam yean
❑ Yes ❑ No
Adjusted gross ineome of appliwnR spouse, and any
individuala aharing ownership (FOrOver 65 deduction, income
may not ezceed 525, 000; for fhe Ovar 65 Circuit Breaker Credi(,
income may not exceed 530, OOO /or individuals, or 540, 000 (or
married couples).
Have Ya (J00 M e(ry
Mave you filed lor deductions in any mher
� Yes � No
?
� Yes ❑ No
i someona oihar �han spouse.
wham
Is ihe pro�arty in puesiron:
Assessed vaNe of lhe prt
torOrei65 detluetiat or
� Real properry � Mobile home (IC 6-f-1-�
. Record numbar Page number
IIWe certify under penalty of perjury that the above and foregoing information is true and conect and that ihe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
AdErasa ot a00�mnt (nwnGm eiN strae4 �M• state. eM ZIP code)
�� o G� o�� =-co--2w i�'-t ��,e-2�
Addresa ot eNhwized reo�asentative (numDe� aritl stroat, ciry, sfate. anC ZIP code)
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