Age_WellsAPPLICATION POR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
` `' State Fortn 43708 (R9l 9-OB)
� P(escnhed by the Dapartmeril of Local Govemmam Finance
IMwmatbn confained in this tlocvment is CONFIDENTIAL purswnt to IC 6-1.1-12-9 and IC 61.1-35-9.
couNn wN � a.FC i
JULF''2�"'�`'2009
INSTRUCTIONS: �-j.h� il �
To be filetl !n person or by mail wifh fhe CountyAuditor o/ Ne county where fhe property is located. 0�� �
Filing Dafes: 1) Real Property: Dunng the fweNe (72) months be/ore Decem6er 37 of the year the deduction is fo��d��OUNTY AUDITOR
2) Mo6i/e Homes essessed under IC 67.7-7 ormanNactu�ed homes rrot assessetl as real property: Dunng Ihe twehre (f2) months
6e/ore March 31 0/ fhe yeer the deduction is to be eRective.
See reverse sitle la addilional insWdions eM qualificatlons.
TYOe of ba�reH fe0uested Weaso Mock a0 Nat apply) I
�Over 65 Deduction from Assessed Valuation /�Over 65 Circuit Breaker Credit
Name d , IrcaM (oxner or cmbac! bqeQ �-k' � `
4.l'%1� /
b aCOG�m tha sda Iepal or eQUitaWe amerl tl No, w�at u hisrher ezaq shara w inteas17 If owned with swneone oNer than soouse.
indi�te with whom
❑ Yes ❑ No
11 neme on recoN is diftarertl than Ihat d apo�canl indicate bebw
Name ot coniraa sellar (ap�cant must nave boon buying m cmvact at roast orce (f) yeaQ
Pdd�esa W mntratl selier (numberan0 sbeat, tiy. sbfa, end ZlPCOde) �s ihe D�oe m Questbn:
Real property � Mobile home (1C 64-1-�
� Tazinq dis(rid . Key numbar I Legal Oescnplion Record numher Paga number
D�-��� �- -/ -/8 - 3 o�f - o0 0. so -o o �
U the Woperty used a:W occupied pnma for Assessed valua of ihe p�ooeny as of March 1, wrtem yeer (may raf exceed Sf B2.d30
hiNher iasidencel lor War 65 detluW'm. ar Sf60,0001ur Ne Ovor 65 Circul 9reeker Gedi�
Yes ❑ No
Was Ne appfimM 65 years o( aBe or mwa on December 37 of the year
Heve yau filed for afry olher detluctionsT �t 1§s, what ded�ctions?
�s ❑ No `y .
Mava yau filed (w daEuctions in eny other couMy7 If Yes, what counTy?
❑ �$ ❑ M� `
IIWe certify under penalty of periury that the above and foregoing information is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Siqnatura appfraM Mtl�easMepplimnt (nwnberanCStreaf,city,stata,aMZlPCOde)
�GC�/ /24 �' y'i'l� ���.G ,.,� iGG �
Spnature of autnwaed �eo�esamative Addresa ot autMrized reo�asantative (numbara� street city, stero, 0 Pcaee)