Age_Stilwell (3)� "' w APPLICATION FOR SENIOR CITIZEN
, - � PROPERTY TAX BENEFITS
S ; Stata Form 43708 (R9/9-08)
Prascnbed by the DapaM1ment of Local Goremmam Finance
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IMormatiom m�taineE in ;his doament is CONfIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9. �/ .
INSTRUCTIONS: �� � N Q�
To be filed in person oi by meil wdh fhe CounryAutlitor ol the county where the property is locatetl. G�gSON QOUNTY AUDITOR
Filing Dafes: i) Ree/ Property: Dunng the Avelve (72J mrnths belore December 37 o/the year fhe tleduction is to be eHective.
2J Mobile Hanes essessed urMer IC 6-7.1-7 or manulactured hwnes nof assessed as real prope�ty: Dunrg the twehre (12) monfns
belore Marrh 37 olNe yea� the deduction is to be eHactive.
See reverse side lw edditlonal instrudions end qualifications.
Type d benafit reoue5e0 (Wo o rheck a0 that epply)
�er 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Nameota0di (owrrerorcont2cibuyo�
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is aoolilant L o!e legal or apuitabia axna�/ If No, what is nisAar exact sna:e or lr.te:est? If owneC vnth someor.e ciher ihan 50ouse.
i�diote w�tn wnom
❑ Yes ❑ No
H name on record is C���fterent Nan that ol aDd�csnL iMiwie babw
Name of cont2a salter (epWiwnt musi haw Doen O�ying on cmbect at /oa9 ono (�) ycah
Address ol wntratl seller (num0ar arro'strooC city, stata, and ZIP cotla) Is ine D�Pe(ty in estion:
eal propery � Mobile home (IC 6-1-7-n
Taaing distrid I Key number I legal dasciptim Record numcer Paga r.umher
� =1 -1 03• D� I D-DO �1
Is 4`�e sed and oaupied wimariy for Assassed value ot lhe �vpeny as of Marth t, curtem year (may naf erceed 5182.a30
hislner rasiCe �ce7 lor O�r 65 doCUrlion. w 5 f 60.0001or tho Ovor 65 Circurt Biwkw Cm7in
❑ Yes ❑ No
Was the a00��m 65 years ot age or mora on Decembar 31 of ihe year
Hava you (Jad far a.ry Mher tle0udions7 It Ves. w�nat Ceductior.s?
� Yes � No
Have you fJed for deducYions in any other counry7 �f �'es. what mvnry?
� Yes ❑ No
INVe certify under penalty of perjury that the above and foregoing information is We and correct and thai the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature d aod'�w�1 PEdress of aoolirart (numDeraM SWef, u.y, s1aro. aM ZiP code)
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Si e olauthonzedreo�esentative� A ssofauthwizedreo.-esentative(num randsbeet.ciry,s(aro.ansZlPcotlo)