Age_Seib1
"'" APPLICATION FOR SENIOR CITIZEN COUNTY � TOWNSHIP �' YEAR
. PROPERTY TAX BENEFITS
� �'• State Form 43708 (R9l 9-08)
� a, Prasaibee by the Depatlment of Local Govemment Finanw
File � ,;
Informatbn oontained in this tloamen; is CONFIDENTIAL pursuant to IC 6-1.7-72-9 antl IC 6-1.L35-9. ��
INSTRUCTIONS: D E C 1 y
To 6e filed in person or by mail wrfh fhe CountyAutlita o/fhe �unfy where Ihe properly is locafed. 1 1� 200$
Filing Dates: 7J Real Propeity: Dutlng [he fweNe (72) montbs belora December 37 of fhe year the tleduction is fo 6 eHective.
2) Mobile Homes assessed urMer IC 6-7. 7-7 or manu/actured homes rrot assessed as real property: D�r ��7��/. monfns
be/ore Merch 37 o/fhe year the detluclion is fo be eHectivs. (�iIB$�N v V
See raverse side twadddional instructions errd quelifications. COU(�TY AUDIT�R
�
`
Typa ot Caneft revue5ed (dcaso rlixk atl Na� apN�
�Over 65 Deduclion from Assessed Valuation Over 65 Circuit Breaker Credit
!�
Name W a o��m (owr�ar orcunnact buyo�
D
Q
Is aoolicam tha sde le6al or eouaaole owneR I/ No, whzt is nis�ner e.act share or inte:ast? It axned vnlh somaoae ciner Ihan soouse.
Indirata wi�n w`om
❑ Yes ❑ No
11 name on racord is diflarent than ihal of a��licant iMicate beiow
Nama o( crntrad seller (app6canf must fuve Deen oaying on car.`act at laa9 orro (1) year)
Pddrass of mntrad seller (number a� sbeet, crry. stalo, erW ZIP mde) �s I�e o�oerty in puestion:
�Real property � Mobile home (IC 6-7-1-�
Tazing disirid Key n ber / al deunplion " �ecord num6er Page number
� 1„ _ / � I �/�a3/`3o�3 �. �l5'r
/`7 CGCL(�
Is Na p�opeM useC eM occuped primanly br Assessed value of �he orooeny as o( Ma¢h 1, curtant year (may not exceed SiB2.d30
hi�/har residente7 (or O�er 65 daduaion, w 5160,000lor Ihe Owr 65 Circuif Bioakar Credi;)
❑ Yes ❑ No
VJas the apd��� 65 years o( ege or more on December 31 of the year Aoplionfs data of bitlh (m '�, day, yoaQ If fJae by a surviving, unmamed spouse,
orror ro n,a a,�rem yean what was the spouse's age a1 the time
� Yes ❑ No qa� oreezv.�
Adjusted gross income of applicant, spouse, and any � Source of Income � Amount of Income
individuals sharing ownership (Fo�Over 65 deduction, income I 5
may not exceed $25,000; /or the Over 65 Cirwif 82aker Credit,
income may rrof exceed 530,000 for individuals, or 540,000 for I S •
martied couples).
. I TOTAL I S � 0.00
Hava you (ded fw any other tleductions? �f Ves, what aeducnons?
Yes ❑ No ��.
Mave you filed fu tleEUCtions in any ai�er munry7 If 1ES. wbat county?
❑ Yes �No
I/We certi(y under penalry of perjury that the above and foregoing information is true and correct and that the applicant was a resident
o( Indiana and owner of the aforementioned property on March 1, 20 _
Sgnature ot avd�m Mdress ot aoplimr.i (numECrar.tl sVeet, ciry. sW;e. and ZIP code)
�,� ��� �_.� � � � .� v.�, N ��.� �' y�6 �y
Signature ol authonzea re�resantalive Mdresa ot auL`.orized raorasantativa (numberand s:reel. ciry. sfaro. ar.d ZIP cotlo)