Age_BurnsAPPLICATION FOR SENIOR CITIZEN opu� wa I YEa.r� i
. PROPERTY TAX BENEFITS
,.. �'- f Sfab Fortn 43708 (R9l 9-OB)
� � i Prescnbad by ihe �epartment of Local Govemmerrt Finance o
Informefion conWineC in Mis tlowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9. J Q L�vT �atk
INSTRUCTIONS: �a� �j'�
To be filed in persm oi 6y mail wiUr the CountyAuditor o/ the county wheie fhe property is locatetl.
FAing Dates: 1J Real Pmperty: During the fwelve (12) marths be/ae Decem6er 37 o/the year the de9i�tr�bAi� rv�u%f�"nA.UDITOR
2) Mobile Hwnes assessed urMer IC fi1.1-7 ormanufecfuretl homes nof essessed as real pioperty: Dunng fhe hveNe (72) months
be%re Mart.� 31 0/ fhe year the deduc6on is to be eHective.
See reverse side lor adddional insWUions arM qualificetions.
Type W beneft reQUasted (p/eaza dieck a0 Nal apply)
�ver 65 Deduction from Assessed Valuation �Over 65 Circ it Breaker Credit
Nameotapd� (wmeracart2cfDUyeQ
is aoo��nt e e Iepal or eQUitable ownaR If No, what is hisR�er exad share or intarast? H owned with someona o�her than spouse,
indimta vnth whom
❑ Yes ❑ No
H nama on record is diRerent Man that d aoW�n4 ��diwte balow
Name of wnlract sailer (appicanf musl have becn b�yirg on cm;ract at least orro (1) yea�
Pdtlrass of wntrad saller (number aM sbeeL cM. sfate, and ZIP wde) Is tne o�Perty in ouesiron:
al property � Mobile home (IC 64-7-�
� Tycin Key number / Legal descAption RecorE number Paga num6er
� o? �-/3.a�p -�U3��a6, 330 -bos
/
Is tha pmperty used an iad �marity for Assessed value o(the oroperry as of Mamh 1, curtent year (may not erceed 5182,d30
hisRiar rasidence7 7or O�er 65 dotludion, or 5760,000 /or Ne Over 65 Cucuif Breake� CreOi�
�Yes ❑ No
VJas Ihe appiicam 65 years ot age or more on DecemEer 31 af the year
Hava yuu filed (or a�ry other daEuctions4 �t 1es. what daductions?
� Yes � No
Have you filed (or Oeductions in any othe� coumy7 If l§s, what wunty?
❑ Yes �No
UWe certify under penalty of perjury that the above and foregoing information is We and wvect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
�
Spnature W apWicaM Mdress ot a0P4mM (numbwantl street, ciry, stale, aM ZIP mde)
� =17/r �(�
• � � � S % 5 O I= ��.e
�,Sig tura of eufhorizaE ra rasentative Mdress of euthorized reprasentative (number and s6eef, city, stafe, and LP code)