HomeMy WebLinkAboutAge_Brackin"' APPLICATION FOR SENIOR CITIZEN
r . _ . PROPERTY TAX BENEFITS
Sfafe Fortn 43708 (R9 / 9-OB)
�. S u�. � P`ascnbed by the DeparUnant of Local Govemment Finance
Infortnatiom m�tained in Ihis tlowment is CONFIDENTIAL pursuant to IC 6-1.7-12-9 and IC 6-1.7-35-9.
COUNTY TOWNSHIP YEAR
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DEC 3 0 2009
INSTRUCTIONS:
To 6e fJed in person or by meil wiUr fhe CountyAuditor o1 fhe cotmty where the property is located. �-y,
Filirq Dates: 1J Real Property: Dunng fhe tweNe (72) marths be/we Oecember 37 o7fhe year the tleducfion is to be:eRa .�','('��j/��
2) Mo6ile Homes essessetl urMer IG 6-7.7-7 or manufactured hwnes nof essessed as �eal prov��S Vu� 1.�N7 Y AUDI I V P 5
befora March 37 0/ the yeer Ihe deductian is to be eHective.
See reverse side la additional inswcL�ons arrc/ qualificatlons.
Type W henefit repuested (ploas a0 fhaf appy)
Over 65 Dedoction hom Assessed Valuation Over 65 Circuit Breaker Credit
Name ot aoG�a�t (owna✓ o+cmf/acf Euye'
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U ap nt N� sde lepal or eQUitabla owneR If No, whal u hisMer ezact share or inte�est'! H owned vnth somaona o�her Ihan spouse,
/- indipte with whom
✓
❑ Yes ❑ No
H name on recoN ia CiRe�em Man thal d applkenl, indiwla belw
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Name m cwnaa ee��erleao��u�r muu nare oeen evylrp m conuaa ef least oire (1) rea� .
' AGEress d mntrad eeller (nWnbm and atreeC dfy, sbte. en0 ZIP cade) � Is the o�oerty in auesipn:
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� � Real property � Mobile home (IC 6-74-�
� Taxing disirid Key numher / Legal descripl'an Record numbar Paga number
l� 6- a- -D3a-oo � s
Is the used end oau0ied primarily for
H3VB )'O{I (�B.') iOlBtP� OI�IBf d84UCiNlfl9i �(�9. Wf18� dBdUCWRS�
❑ Yes ❑ No
Have you fded tw Eoductiona in any other cwMy7 il 19s, whal coumy?
� ❑ �S o Na
IIWe certify under penalty of peryury thal lhe above and foregoing information is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signatura o( apd�cem � Mdress of aDDti�m (nunEa aiW shoe�, ciry, state. arH Z/P code)
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Signatureota onzedrepreaemative Addressofeulhoriza raoresentative (numDeraMs' tiry,sfato, ndZlPcode)