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�r APPLICATION FOR SENIOR CITIZEN
r . . � PROPERTY TAX BENEFITS
` �,• Slate Foem d3708 (R919-OB)
� Prescribed by Me Departmem of Local Govemmem Finance
Informatiom m�tained in this dowment is CONFIDENTIAL pursuanl to IC 6-1.1-12-9 and IC 61.1-35-9.
INSTRUCTIONS: C
To be fileC in person or by mail wiM Ure CountyAuditor ol fhe counry where �he property is locared. APR i/ Z�.� : �
Fifing Dafes: 1J Reel Property: Durirg the tweNe (72) mmNs 6efwe December 31 of the ysar the tleduction is to 6e e/tective.
2J Mobile Hames essessed urWer IC &7.1-7 or manNactured homes rrot assessed as real property: Dunrg th��fhs
be(ae Martit 37 0/ the year the deduction is to be eflec6ve. �`�
�_
See reverse side ta adddionel insfirctions eM qua/ificatims. OIB$ON COUNTY A;::;! �;;:.
TyDe ot Cerref� (epuested (yleam tlieck ell lhat eppM
�Over 65 Deduc6on from Assessed Valuation � Over 65 Circuit Breaker Credit
Name of applicant (orner or cmbaQ DvyeQ �
t
f
U BDD��M Ne bde lepal or eQUitable owne If No, what is his�her ex shara w interesl7 H ownetl with sanaona other lhan spouse.
� inditatewithwhom
❑ Yes ❑ No
If riame an record is diferant Ihan tlut ot a0o�nt ���ie hebw
Name ot contreG seller (epplicenl must have baen buyirg on cmLact at lea5 oire (iJ yeaQ
Ta+�ing disind
saAer (numDer and sneet tlfy. stab. aid ZIP wde)
Key
l J( 9�JL?�' ��{"JlJ lo(fo �/ O- V/�
Is �he O�OeM used aM omped primariy br
hivhar residenm0
❑ Yes ❑ No
Was i�e eDd� 65 yeara ot age or rtiae on DecemDer 37 of the year '
o�or to tne artem yean
❑ Yes ❑ No
Adjusted gross income of appliean; spouse, and any
individuals sharing ownership (ForOver 65 deduction, income
may not exceed 825, 000; for the Over 65 Circuit Breake� Credit,
income may rrot exceed $30,000 lor individuals, or 540,000 for
married couples).
Hava you fled for a�ry dher dedutEOns7
� YES
any other couMy9
❑ Yes
� No
� No
II•8 O�DBfI)' Ifl pU85ip(1:
�Real property � MoDile home (IC 6-7-7-�
Record number Paga number
- OOO: J�30-OJ-.Z �
Assessed raNe of the poDarry as of March 1, wrrem year (mey nof arceatl S iB1,C30
fi� O�er 65 deduCian, or t160.000 !or Ne Woi 65 Cticnit Braekar CradiQ
I/VJe certify under penalty of perjury that the above and foregoing in(ormation is true and cortect and thal the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 7, 20 _
Signature of aopilcairi Addreas of a001irem (numberend stroeL ciry, slata, aM ZIP code)
�.� � � � �- o �t '. s'c o�-- -�- Sr��,�p� �
Sunature of authwiz D�asantative Address ot auihonzad re0�asentativa (numbera�W sfroet ciry, sfafo, an0 Z/Pcotlo)
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