Age_FergusonAPPLICATION FOR SENIOR CITIZEN
, PROPERTY TAX BENEFITS
` ' State Form 43708 (R9 / 9�U8)
� Prescnbed by Me Departmefn of Local GovemmeM Finance
Infwmatiom m�tained in this dowment is CONFIDENTI/LL pursuanl to IC Cr1.1-12-9 and IC 61.135-9.
IISCyGi�LNIC�P.FYi
COUNN I TOWNSHIP � YEAR
� �
To be fi/ed !n person or 6y mail with the CourrtyAudrtw of Ne ooun y wheie tlte property is located. �i I� 2 Q'tQQ9
Filing Dates: 1) Real Property: Dunng fhe hveNe (12) monfhs be/wa Decem6er 31 0! the year the deduction is to e e ecfrve.
2) Mobile Hanes assessed uMer IC &7.1-7 or menu/actured hwnes rrot essessed as reel pmpeAy: Dunng fhe twe�,(12) months
6e/ore Marrh 31 o/the yeer the deduction is fo be e9ective. ��a��
- - _ _ �%la%I C/_._....
�eeroveisasma�uaaaruvnrunuwww�sairtiV�nn�iwu�wu. QUi�TY AUUIIV��
Type af beneft repuedeE (peese dieck e9lhat appj�
er 65 Deduction from Assessed Valuation �Dver 65 Circuit Breaker Credit
Name dapd�M (Ow�rer 1 buye� '
la applitarrt ihe ade lepal or epuitade owneR If No, r u his/Aer �ad shaea w interast7 If owned wilh swneme mher Ihan spouse.
indirata wiN wMm
� Yes ❑ No
If name on ramrd ia dilfe�aen Man lhat d epplimnt, indkste babw
Nama d cwnraa san r/app�¢ant must nave eem, eyvg m oonvaa a� �eas one (71 r��
1 1
nddress G mntraa w r(nwnber aM sboo4 crly. sdfe, and ZIP oode) Is tne orouerry in ouestior.:
� Real property � Mobile home (IC 6-1-7-�
� Taxinq distriq Key number / Legal description Record number Page number
��?.Q,�,Q- a�-��-���a-�a.3S -��
U Ne propary used and occupeE prvna' r 0.ssessed value of lhe properry as at Ma¢h t, wrtant year (may rrot erceed Sf B7 d30
his�her residenoT /o/ O�er 65 CoOUGim. w 5160,000 lor Ne Over 65 Circue &oakar Credit)
�Yes ❑ No
Was Ue e00��165 years of age or rtrora on December 31 d iha year
Have you filetl tor arry olher deducfiona9 �� �§s. what deducoons?
� Yes No
Have you filed tor deduc0ons in any other courrtyl I( �45, what caiMy?
❑ Yes ❑ No
IlWe certify under penalty of perjury that the above and foregoing infortnation is true and correct and that the applicant was a residenl
of Indiana and owne� of the aforementioned property on March 1, 20 _
Signatu(eolapplkam AddresaotaDD��m�i (nwnOOraMStreetci.y.stato.andZlPcotle)
�:�.. ;-�u7� ' , u L B c� h r - sr� �.�c � r-, z.-v
Sgnatura d auNOrized �epresam e Address o auchorizad reoresenWtive (number a�M stroot, c- , state, anC ZIP cotla)
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