Age_White� APPLICATION FOR SENIOR CITIZEN couNn TOWNSHIP r�
^ PROPERTY TAX BENEFITS �
State Fortn 43708 (R9 / 9-08)
� ' t ares�ma q �ne oepartmem otiowi co�am�,am F�nanca
II
Infortnation cantained in this tlowment is CONFIDENTIAL pursuant to IC 6-1.142-9 antl IC 61.1-35-9. QPR 2�����
INSTRUCTIONS: C.�.M�"
To 6e filed in peram or 6y mail wiU� fhe CounryAuditor o! the wunty where tl�e property is located. v �
Filing Dates: 1J Real PiopeRy: Dunng the tweNe (12) months 6elrne Oecem6er 31 0l (he year the tleducti�a��� �$�T�,p �(�� n{�
2) Mo6ile Homes assessed under IC 6-7.1-7 or manWactured hanes rrot assessed as reel pioperty.� Dunrg fhe lwe(re (�Z) rtT6riths
before MarGt 31 0! the year the deduction is fo be etfective.
See reverse sde ta! addAional insLVUions and qualifications.
Type U baneft rapuesied (please rheck aID lhat apply)
Over 65 Deduction from Assessed Valuation I ld Over 65 Circuit Breaker Credit
%
or camau w
9 �- o-n� � � �/u=�
❑ Yes ❑ No
�f name on remd is
Name d contrsG seAar
on
at is hisRier ezar� share or irrtereslY
oire (71 Y�d
If owned with mmeone oiher ihan spause.
indiole with whom
Address d contratl m0er (number eiM street, rily, slab, ai0 LP coda) Is the p`ope(ty in question:
eal pmperty � Mobile home QC 67-1-n
� Tuing distrid Key num6er / Legal descriptim Record number Page number
a�-/ 9-3i :�/ 060. 9 3-
Is ihe pmparry used ard oavpied primariy (or Assessetl value of the qoperry u of Marcl� 7, curtafri year (may rpt ermeE SiH2.430
IJsThar rasidence? PorO�e� 65 dedurl.un, m 5766,000 toiNe Over 65 Cirnil &ealmrCradiQ
❑ Yes ❑ No
VJas Ihe appG�aM fi5 yeara of age w more on Oecember 31 of lhe year
pnor to Ma airtem r�n
❑ Yes ❑ No
Adjusted gross income of applicanR spouse, and any
individuals sharing ownership (ForOver65 deduction, income
may not exceed 825,000; /or the Over 65 Ciicuit Breaker Credit,
income may not exceed 830, 000 for individuals, or 340.000 (or
mamed couples).
you fJatl For arry other deductions?
Yes
youlJeE tor aeE�ctions in any olher munry7
❑ YCS
� No
1�, .
�
I/We certify under penally of peryury lhat the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signalura ot appfirattl
�
PddressotaOG�m (nwnOeraMstree4�'+ry.sble,andZ/Pwde)
Addressa(au�horimdrapresenlalive (numboiarWStmet,dty,4afo,andLPtado)