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APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
Stam Fortn a3708 (R9 / 408)
Prewibed by the Depertmem of Loral C,ovemmem Finance
Infwmatiom m�tained in [his dowment i5 CONFIDENTIAL pursuant to IC 6-1.1-12-9 anC IC 6-1.135-9.
iNSrRUCnoNS:
To be filed !n persan or by mail with Ure CountyAudrtw of fhe county where the property is located.
COUNTY TOWNSHIP � YEAR
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APR 2 2 Z010
Ftli+g Dates: 1) Real PropeAy: Ounrg the fweNe (12J ma�ths be(ore Decem6er 37 of fhe year fhe deduction is to be eflecUve. .
2) Mo6He Homes essessed urMer IC &7.1-7 or manWactured homes rwf assessed as reel prope �(12) months
be/ae Me/di 37 olthe year the deduc5on k to be eflecWe. CO�NT� A����
Sww mvwrcw dAw hr wdA�7ionnl lneLUdiuna end aualifirations. :�BS�N
TYOe ot beneft re0uesied (ye�pfMOCk � Nef apply� .
/
jYOver 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credif
Name W epd��i (ownei w confracf Ouyo�
V � .�
b a00��� sde legal If No, what is hisiher exect 6hare w interest? tl owned wilh mmawe d�er Ihan spouse.
�indita�e wilh whom
�' ❑ Yes ❑ No
N name on recard is dHfe�eM Man thal d eoWifanl, i'Miwte bebw
Name of contacl sellar (�pp''mant musf hare Doen Otryirg on conl2ct et leasf ono (1) yoa�
/dCress of mntratl seller (numbar aM streeC city, stefn, and Z/P wde) �9 IhB D�ODBM in stion:
eal pmperry � Mobile home (IC 6-7-7-n
� Taningdistrict Kaynumher/�epaldeunotbn RecorEnumber Pagar.urher
a- - -o- .�a-oo
U Ne ptopeM �s� an0 occupietl pnmanly br Assessed value ol ihe prooe as of March 7, wnelri year (may �rot exceed S1H2.<?0
ro
his/har rasbenw7 !or Orer 65 deduGion, a t7 .00O lor Ne Over 65 Cucuif B�oakor Credi�
❑ Yes ❑ No
VJas the appficaM 65 years of age w mara on December 31 of the year
Have you filed tor erry othar deductiona7 If Yes, whal deductions7
� YeS !o
Have you fAed tor deducYions in any other cou�riy? If 10s. what counry?
� YBS O
UWe certify under penalty of peryury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owne� of the aforementioned property on March 1, 20 �
$ipneture a(apqicarit Pddrass of e00��wn� (numberand sboof, ciry, afate, entl Z/P wda)
' � � � P�C,c.v►n I-lC�u.,lr-
� etura dauthonzetl represeMative Addrasa of eulhonzed rep:esentative (numberan0 stmeC ciry, state. an0 LP codaJ