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a APPLICATION FOR SENIOR CITIZEN couNn � TOWNSHIP � YEAR i
.�'. PROPERTY TAX BENEFITS I
� Stata Fortn 43708 (R9 / 9-0e)
Prascnbed 6y Ihe DepaRmenf of Local Go�emmerit Firanca
File Mark �
Intwmatiom m�tained in this tloament is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9. �
INSTRUC710NS: �
To be filed in persar or 6y mai/ with tAe CountyAudita o/ the county wheis the property is loca[ed.
Filing Dates: 1) Real Property: Dunng the hveNe (12) months 6e(ore Decem6er 37 of the year fhe ded�ction is t�ec � q �1Q0�
2J Mobile Homes essessed untler IC 6-7J-7 ormanulactured hwnes not assessed es real pmperty: ng the Me� �) kronths
be%re Marth 37 0/ Ne }rear fhe tleduction is to be eflec6ve. Q�' X�^
See reverse sMe 7a adtldional instn�ctions erid quelifica6ons. � I' �\.�pP
Typa W benefit raGUaste�d (ploa5o MotkaO Naf appy) � � `N�(� I
Over 65 Deduction from Assessed Valuation Over 65 Circuii Breaker Credit gSpN "
Name d aOOGca � cantract DuyoQ
' ��� r ��
Is ao0licam tha le iegal or eQUitabie mmer/ I o, what is hisfner exact share or irterest7 I! owned with someone other ihan spoase,
indimte with whom
pn rewtd is
Name of
mntraC
�Yes ❑ No I '
Nan lhat o1 aoaikanl indiwte bebw
on conuact at /east ono (il yoa�
(numDa aM sboe; c2y, staro, aM ZIP cotle)
Iha o�oerry in auestion:
Real prope ,ry � Mobile home (IC 6-7-7-�
� egai scry��ion ? Reco n/um�bar Page r.umbar
%6/ aJ � �• �/'� �
Is ihe DraoeM used an0 occupietl o�many mr �
hisiher residence?
Yes ❑ No
Was the aoM�M 65 years of age or mwe on December 31 of lhe yaar
odor to tha airram yeafl <�
y,�� Yes ❑ No
r�
Adjusted gross income of appliea t, spouse, and any
individuals sharing ownership (For Over 65 deduction, income
may not exceed 525,000: (or the Over 65 Circuif Breaker Credit,
income may not exceed 530,000 !or individuals, or 540,000 for
married couples).
Have
Mave yau llad
fof am/ othar tleduaions7
� Yes
any other counry7
❑ Yes
� No
No
0.ssessec value of Ihe orc
br O�er 65 dMUUion, w
Income
If Ves, what aedvcfior.s7
ffis. wnat wuniv?
i 1. wr.ent yaar �may not c+caotl StB1.<30
Ova� 65 Ci2vit &vaker CaHR)
If filec by a survivlr.g, un:nameC sxuse,
what was Ihe spocse's age af ihe time
of deam7
� Amount of Income
IS
IS
TOTAL ( S
INVe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
ot Indiana and owner of the aforementioned property on March 1. 20
� Siqnatura of aoW.wm Address of aoo��mm (number and swcl, ci.y, s:are, and ZIP cnde)
�." ��� L? �' � .
Sgnati��e of authoozed raOGasentative ACcress of auihwixac raaaserta4va (number antl s:me[, ci.y, sta;e, and LP coCe)
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