Age_Simmons" APPLICATION FOR SENIOR CITIZEN
__ . PROPERTY TAX BENEFITS
Slala Form 43708 (R9l 9O8)
l�� S,•i � Prescnbed by ihe Oepartmerit of Local Govammeirt Financa
Infortnatbn eontainetl in Nis dowment is CONFIDENTIAL pursuanf to IC 6-1.1-12-9 and IC 6-1.1-35-9.
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COUNTY TOWNSMIP YEAR
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INSTRUCTlONS:
To be Red in persm or 6y mad wRh the CountyAud"Aor o7 the county whera fhe property is located. �1��,�. 9
Filiry Detes: i) RealPropelty: During the lweNe (72) mmths be/we Decem6er 31 ollhe yeartt�e tleduction is to 6e 9necavq7 ZQ�2
2) Mo6ile Nomes ascessed u�er IC b7.7-7 o�manulactured homes rrot assessed as 2al property.� Duri fh�Me M��--.sy��glv-�e- --(12) months
6e�ore Mart.fi 37 0/ fhe year the deduction is to 6e eRective. C�� �
See reverse side for additional instludions antl qualificatims �
Type of
Nama d apqiram
v a�r�m me sde iegai
Ove� 65 Deduction from Assessed Valuation
If No, what �s his/her exad
�Y� u No �
�r wn,e on rema fs aiRerem wn u,z+or sod��c uiaKete eew«
d conlaa seoer
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buy'ug m canhad at /easf o� (1) yea�
❑ Over 65 Circuit Breaker Credit
If ownad with someone olhar lhan spouse,
iMirate wiN wfmm
city, sfab, alW LP coda) Is lhe pmpetly in question:
� Real pmperty � Mobile home QC 6-74-�
Key number / Legal dessiption Recrnd number Paga number
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Is Ihe pmpeM �� aM ocwpied primariy br
his/ner residenw7
❑Yes ❑No
Waa Ne aOd�M 65 years ot age d mora on Oecamber 31 of tha year
prior to the airtaM yea/7
� Yes ❑ Na
Adjusted gross inwme of applicanR spouse, and any
individuals sharing ownership (ForOver65 deduction, income
may not exceed %25, 000; for the Ove� 65 Circud 62aker Credit,
income may not exceed 530, 000 for individuals, or 540.000 /or
married couples).
Mave you fJed for arry
Have yw filed for deduciions in any W her
�Yas �No
❑ Yes ❑ No
e/. UG� - c� % I I
Assessed vaNe ot the properry as of Mafch 1, wrtan� year (may rrot erceetl 57H2130
lorOrer 65 detlucfim, w 5160,000lorNO Owr 65 Ciicin'1 Brealrer Credi�
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UWe certify under penalty of peryury that the above and foregoing information is We and correct and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
5gnatureotapq"rarit PAdressotaOP�m (nun6eiaMs6eeGtlty,stafo,arMLPwdo)
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Siona uta ' ed reorasenta6ve Pddress of autMrized repremntativ (numberaM s 4 aN. s(efa endLP �