Age_Alvey�' APPLICATION FOR SENIOR CITIZEN couNrv TOWNSHIP � YEAR i
� � PROPERTY TAX BENEFITS
State Far.n 43708 (R9/9-06)
Pawibed by Ihe OepartrneM of Lacal Govemmam Finance
Ile
� Informatbm m�tained in this tlocumenl is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC G7.1-35-9.
INSTRUCTIONS: APR��1 1 ZO��
To be filed in person o� by mail Mith Ne CountyAUd'Ra o/ the �unty where fhe properry is locafed.
Fili� Dates: 1) Reel Property: Durirg fhe hveNe (72) marths 6efore Decem6er 37 of the ysar the deduction is to be
2) Mobile Homes essessed urWer IC 6-1.7-7 o�manufactu�etl homes rat assessed as real property: Dunry ffie hve w��s
befae March 37 01 the yenr the deduction is fo be effective. � (3�g$ON COUNTY AU TOR
Sea reverse sitle 7or adddional insUUdions erM pual/fications.
�Yoa d eenef� rea�aeed (d�� rlrecir a9 uwt a� � �
�Ovar 65 Deduction hom Assessed Valuafion �Over 65 Circuit Breaker Credit
T�
Name appfKant (owrrer a contrad DuyeQ �
/ �
�- �
/w /
b BD7�itarii the sde lep eQUitaWe awneR If No, what i his/her exect ahare w interest7 N owned with someona other than spouse,
� indimte wit� whom
❑ Yes ❑ No
M name on rawN is diNe�em Man Mal d app&snt, indicale bebw
Name d comrect se0er (epylcant must fiave boon euyinp m cmMacr at least orro (f) yeaQ
Add�ess d contrad m0er (numbara� sbae4 dly. s6ta, eM ZIP mde) �s tne P�oPe(ty in Question:
Real properry � Mobile home (IC 6-7-7-�
� 7���e disincl Key number I Legal dascnpiion Recafd numDer Page number
- - -' a3- ao.3�51 aa
l5 ptOperty used enE otCUpieE D M' �r Assassad vaNe ot the DroDeM as af March 1, wrrent year (may irot oxceed Sf B2,430
hiaher residenw7 fw O�er 65 UoOUCtim. m 5760,000 /oi Ne Over 65 Circuit 6eeker CrediQ
❑ Yes ❑ No
Nha Ue a00�xarrt 65 yean oi ape or rtwre on December 31 of the year Apo�nCs date of birth (mmN, tlay, yea� I( filed by a surviving, ur..mamed spouse,
prior to the arterrt yea/7 what was the spouse's age at lhe time
❑ Yes ❑ No otaeau,?
Adjusted gross income of appliwnR $Pouse, and any
Have you (AaE For arry aher deductions7 �( Yas. what daductions?
� Yes � No
Have you filed for tleCUCfmru in any oltier courtty? If Yes, whaf county?
❑ Yes ❑ No
I/We certify under penalty of perjury lhat lhe above and foregoing infortnation is Irue and correcl and that the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Sipnatura of appllcaM MCrass o1 eoP��t (numberemi stroo4 ciry, sfafe, aiM Z/P wde)
o�+�.—
� ipnelure M aNhoAzed re tive Address ol eutlrorizad represen�ative (numberand s✓eeL ciy, sfafo, antl LP roda)