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Age_RichardsonAPPLICATION FOR SENIOR CITIZEN �P Y�
._-rt• a- PROPERTYTAXBENEFITS
• ' . � Stata Fwm 43708 (R919-08)
•� � Peesuibed by �he DepaRmerit of Local GovemmeM Finance
� Informatirn mntained in this doament is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. � E C � G ZU7T Mark
INSTRUC710NS: C ",' n1°``�(�"""'�
To be filed in person or 6y mail with the CountyAud"Aor o7the county whele fhe ryoperty is bcated. V v
Filirg Detes: 7) Real Property: Dunng the hveNe (72) mmths hefare December 31 of fhe yearlhe de�18AQYAlt6/TMAf4ec)hdUDITOR
2) Mobile Hanes essessed under IC &1_ 1-7 or manWactured hanes rrot assessed as real property: Dunng the twsNe (12J monUis
6e/we Marrh 31 of fhe year the deduction is fo 6e effecWe.
u
�
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See reverse side Iw additional inshudions arM qualificstions
Type d beneH repuasted (J.dease dieck a0 Nat apply)
{J Over 65 Deduction from Assessed Valuation �[y Over 65 Circuit Breaker Credil
Name d appfrant (annar or cmfrdcf Duyerj
/� � . .
Is a fimM lhe sde lepal or eQUitaWe owna(7 H No, what is his/her exad share or inlerest7 If awned wilh someone oiher than spousa,
inditate xith whom
❑ Yes ❑ No
It name on recad'n tliftarerit than Iha1 d apqican4 iiWicate bebw
Name of conlaG seDer (applrcant musf hare been D�ryirg m cmlrad af ba5 orie (i) yearj
Pdtlress ot cvnbatl seller (n�m6er aM sbaef, city, slale, and LP o000) Is lhe property in queslion:
�fteal pmperty � Mobile home (!C &74-n
Tani� datrid Key number / Legal desc+iptian Record numbar Paga number
Oa-�eo-� -1y-19-10�-oDO, 531- 07
Is Ihe qoperty usetl aM ocwpied rily (or Auessed waWa of iha pmperty as of Mamh 1, wrrerit year (may rrof nrraed 5782,a30
hisfiar residence7 /w 0`er 65 deEUdivi, u� E760.O00 /or Ne O�m165 C'vcmit &ealmrGadiQ
❑ Yes ❑ No
Wav the a0d�m 65 yaars of aga or rtrore on Decembar 31 of lhe year
Have you filed tn airy other deduct»ns7 If Yes, what deductions?
C�'�s ❑ N° I.� . S .
Have you fYeO fw daducGOns in any olher wunty7 If �4s, what couMy4
❑ Yes ❑ No
IIN/e certify under penalty of perjury that the above and foregoing infortnation is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Sign uredappGpnt AdCressofapplimnl (numberarMSboeLaty.sbfa,arMZlPmd¢)
� � J � `/r
nalure o( aulhor¢ed resentative ACdrass of aNtror'rmE reprasentat'rve (number arM sLOet, cify. �at4 enE ZiP w0e)