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APPLICATION FOR SENIOR CITIZEN
. . PROPERTY TAX BENEFITS
S J Stafe Form 43708 (R9 / 408�
Pfascribed by the DeoarhneM of Loral Govemmem Finarice
co n o Ns � YEAR
Infortnation oontained in this doamenl is CONFIDENTIAL pursuant to IC 6-1.1-12-9 antl IC &1.135-9. p,P f� `� afk
INSTRUCTIONS: `�y�/yyy��� �
To 6e filealn persm o� by mail witA the CourrtyAudita o/ fhe county whera tlre property is located. �/ "'�$Y A p�fi8a
Filirg Dates: 1) Reel Pioperty: Dunig fhe tweNe (12J morttfis be%re December 31 o/the ysar fhe deducptiq�pp� e.
2) Mobile Homes assessed under IC &7.7-7 or manu/actured hwnes nof essessed as reel prope�fy.� Dun� the twehre (12) months
before March 31 0/ the year the deduction is fo be eiFective.
See reverse side lor edditionel insUUQions a�d qualifications.
Type W Eenefit reQUested (p/ dieck e0 thet eppy) /
/
Over 65 Deduction from Assessed Valua6on �;�rOver 65 Circuit Breaker Credit
Name d eparxaM (amer a cmUact Duyep �
��- �, � �Q��
L4 dp0�k2ni LhB s ' o� apuitade OwnB!! If No, what u hiSTher ezac� share w inte:ast9 If owned with someone othar Ihan sOw�se.
intlimta wiih wMm
�❑ Yes ❑ No
tt name on recortl is difterant Nan thal d applican4 ��dicete bebw
Nama of mntratl seller (eppicanf must here Oeon buyirg on cmVacf af bast one (1) yoa�
/ddress of mntrad sePer (numOm aM streal. ciry, state, eiM ZlPwde) Is Ihe o��eM �n ouestion:
� Real property ❑ �MObile home (IC 6J-f-n
� TaxirgdistriC Keynum5ar/LepaldescnGtion Recordnumber Pagar.umDar
6•0 - S-'�co-000• s4 E 4
Is Ne pmperty used and accuqed primany 1w Assassed value ot the Drooerty as ot Mamh t, wmem year (may nN erceed 57B2,d30
hislner reskenca7 lOr 0`cr 65 EoduC:an. or 5160.000 hr No Owr 65 Cwicuit &oakw C/edi�
es ❑ No
Was the eDd� 65 yeare ot age w rtrore on Decemeer 31 ot Ihe year Mv����' yearJ If flea by a surviving, ur,;remed s0ousa,
prior to Me artent yeaY! ' �_�_ � ' what was the spa�sa's age at lhe lime
� Yes ❑ NO otdeath?
Adjusted gross income of appliwnt, spouse, and any Sou ce oi Income Artrount of Income �
individuals sharing ownership (For Over 65 deducfion, rncome �� / '
may not exceed 825,000; for the Over 65 Circuit Breaker Credit, V •
income may not exceed $30, 000 for individuals, or 540, 000 for I S '
married couples).
� TOTAL $ 0.00
Have you filed lor a�ry olher detluctions7 �f 14a, what ded�ctions?
�Yes ❑No
Nava you filed far deduc0ona in any dher courtty? I It Ves, what co�my?
❑ Yes ❑ No
IlWe certify under penalty of peryury that lhe above and foregoing information is true and cortect and that the applicant was a rasident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of appficarit AdE�asa of eppli�nt (numbaaM stroof, ciry, sfafa, and Z/P wde)
� n u orizetl reO�eMaOve Address ot aNhorized reprasenialive (numDer aM SLael, city, state, end LP co0e)
5/ .- ryt R P�Irv�f'�