Age_MatselAPPLICATION FOR SENIOR CITIZEN
�; PROPERTY TAX BENEFITS
S Sbte Fortn 43708 (R9 / 9-0B)
� � Prescd6ed Oy Ne Depatlment o/ Local Govemment Finance
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Information oontained in this tlocumen� is CONFIDEN7IAL pursuaN to IC 6-1.7-72-9 and IC 6-1.7-95-9.
INSTRUCTIONS: G/BSO��t .��
To be fiJed in person or by mail wilh the CounlyAUditor o1 the county where Ihe pr erty is located. N CQ
Fili�q Detes: 7) Real Property. Dunng (he fweNe (72J mon.fhc be/ora Decem'6� 31 01 fhe year fhe tleducfion is fo be eHec�i eT y A Q17
2) Mobile Hanes assessed wMer IC 67J-7 ormanulactured homes rrof assessed as real pmpelry: Dudng Ihe fwelve (72J�rr�nfhs
6e/aa Me�ch 37 0l fhe year fhe deducfion is lo be e/lective.
See reverse side 7w eddifionel lnsWdions alM qualificatims.
Type d beneH reQUesieO (poaso Mock aD Naf apply)
Over 65 Deduciion 6om Assessed Valua6on � Over 65 Circuit Breaker Credit
Name of a0 '� M(o� a cmfracf Dyyo�
C..� ( /7
( /.� C.I�
Is a M Ihe sde leyal ore uilaMe wmeR If , what is hislber ezad share or �.teras�7 If ownad with someone olher Ihan spouse.
indinta wit� whom
Yes ❑ No
II name rn recortl is difte nl ihan Ihat ol aoWi��l indicale belpw
Name ot mf12C sellar (epd��nf mu5( fww bcen buyirg on canfracf at leasf orro (7J year) �
Pddrass ol contrad se0er (numDor xM sbcof. cM. sWfi. aM ZIP codo) � Is ihe omoerty in puastion:
Real property ❑ Miobile home (IC 6-14-n
7xvinp ' �nq I Hey number I L al descnF�ion I RacorE num56r Page number
q�p - O�b?.S'-/O/ -�. c��a� - Q�? O
Is Ihe poOeM useE and occuped pnmanly br Assessed value ef tSe vmoerty as ol tAarU 1, cur.ent year (may nW crcecd SiB1,a30
hiyher residence7 for O�er 65 doduflio , w 5160,000 lor Ne Ovn165 Circuif &eaker C2d��
Yes ❑ No
Waa �he aDO�m 65 yean of ape or mora on Decamber 31 d I�e yaar
Have you (Jad tor any other deduGbns7 If Ves. wnat Ceductions? '
Yes � Na y s. .
Hava you filad for Cetluctions in any dher counryl If Yas, wnat covnty?
� Yes No
I/We certify under penalty of perjury that the above and foregoing information is true and corred and that the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature d aDD�nt Address ot a00��mm (numberand sLeeq c�y s1-te. tl ZIP code�
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ature d eulhwized re0resamaliv¢ ACdress af authorized raaresentative (rumJCr ar,d s✓eet, ciry, sta(e, antl Z! cado)
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