Age_Stone�APPLICATION FOR SENIOR CITIZEN
R. � PROPERTY TAX BENEFITS
` "' Sqb Fortn 43708 (R9 / 8-08)
Prescnbed by the Departmenl of local Govemment Finance
Infwmatqn wntained in this dowment is CONFIDENTIAL pursuan� to IC 6-1.1-12-9 and IC 61.7-35-9
COUNTY TOWNSHIP � YEAR
1
File Mark
MAY 1 3 2011
wsrRUCnoNS:
To 6e filed in person or by meil wifh the CourrtyAutlifa o! the wun y where fhe property is located. C���
Flliry Dates: 1) Real Property: Dunng the tweNe (12) months befae Decem6er 37 0/ the ysar the tleduction is fo be e
2) MobdeHamesassessedurMerlC6f.t-7o�manulacturedhomesrrotassessede.j�gQ}�iA3Q�E6Tii4�i��li�j72)months
be/ae March 37 0/ fhe year the detluction is to be elfective.
See reverse side lor addilional irtcUVCtions arW qualifications.
ryoe m cenefc (eooaseed W�� rnak ea u�� a�
Ove� 65 Deduction from Assessed Valuation Wer 65 Cirwit Breaker Credit
Name of apdkarit (awner a conhac+DUyeQ
�
U eGPliqrit Ihe sde lepal or e taMe owna(t i NO, wh21 i9 ht9/(iBf Bz8[� 9hdfB O! it128�B51? It mvned with mmeone Wher than soousa.
inditlte with wham
❑ Yes ❑ No
tt name on (ewrtf is di9areM than Ihat ol apd�cant, indiwta bebw
Name of mitad se0er (applicanf must hare Eoon buying m conuaa at lea5 orre (1) yeah
� Addreas ol contrarl seAer (numOw aM sboat vry. stata, and ZIP code) �9 t�B D�OOBhy in Queslion:
eal property � Mobile home (IC 6-7-7-�
Tazing d�ist"'�' Key num6er / Legel dascAOtion Record namber Page numoer
(�a.,� �iv„ c✓ ' i � - - o a-a� /� o (o _
Is ihe O�DaM1Y �sed a(W occupeE pnmarily Assessed value oi Ihe Dm�eM as of Ma¢h 1, curtent yaar (may nW e+ceed 5182,d?0
Aivher rasdence? foi 0`er 65 tlotlueion. ar 5760.000 !w No Ovcr 65 Cirnnf &oakor Credi�
�Yes ❑ No
Was �he app�ica�ri fi5 yaars of age or mMa on Dacember 31 d lhe year
Mava you Fiied tor e.ry other Eeductions7 �f Yas, what deduction57
� Yes ❑ No
Have you filetl for deductions in eny othar caurrty7 If Yes, what counry7
� Y0S O
I/We certify under penalty of peryury that the above and foregoing information is true and correct and that the applicanf was a resident
ot Indiana and owner of the aforementioned property on March 1, 20
� Sipnetu appficar�t AEdrasa of evOGfaM (nun6aantl sboe4 �: sfate, aM Z/Pcode) —
� /� �- �' � �
Sign of euNOrized reD�eaemative AE s oi eWhorizad reo�ase�tatrve (numDer aM sucet, ciry, state, antl LPCOdo)