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���APPLICATION FOR SENIOR CITIZEN
t PROPERTY TAX BENEFITS
� f Stale Fortn 43708 (R9 / 9-OB)
P�ewibeA by ihe DaparimeM of LoW Go�emmertl Finance
COUNTY TOWNSMIP YEAR
FI - - .
tle Mark
Infortnation contained in l�is tlowment is CONFIDENTIAL pursuant lo IC 6-1.7-12-9 and IC 61.735-9' IAY
IVI 0 9 2012
INSTRUCTIONS:
To be filed in person or by mail with fhe CountyAuditor of the county where the proparty is locafed C. �.
Filing Dates: 7J Real Property: Dunng tha hveAre (12) monfhs 6e/ae December 37 0/ the year the tleduction i b eclire.
2J Mo6ile Hanes assessed urMer fC 67.7-7 or manufactured homes rrot ass���e���a�: OR r+e (12) months
befae March 37 of fhe year the deduction is to 6e e//active.
See reverse side !or additional insWCtions arM qualificalims
Type ot banefi raquestetl (p/easa diack a0 fhaf appJy)
� Over 65 Deduction hom Assessed Valuation �Over 65 Circuit Breaker Credit
Name of appi'ranl (owrrer a� cant2clWye�
.— y .'
U appl'uaM lhe sNe lepal or aq able ovmaR If No, what is his�her ezar� shara w iMerest7 If owned with mmeone olher ihan spousa,
i'Minla with whom
❑ Yes ❑ No
If name m recwd'u diRarem Ihan ihat of eppGcant, iMicale bebw
Nartre ot co`rt�acl se7er (app(mant must have beu� Guy(rg m mNad af loast o� (1) yea�)
AdCress W mntrad seller (nwnbar ariC streef, city, slale, arM ZIP codb) Is the pmpeM � Quas�iwr.
� Real pmperty � Mobile home (IC G7-1-�
Taxi�rict Key numbar / Lagal descnption Racmd number Page number
—O _ 2. 1.0 O oZ
U Na yoperty used eM occupiaE primar�y for Assessed vaNe ot ihe poparry as ot Mart�lf 7, wrtaM year (may naf eireeE SiH2,430
his/her rasiEanm7 IorOrer 65 tletlurlan, a- 5160,000 (or fhe Ov¢i 65 Ctinol &ealmr CrvdiQ
❑ Yes ❑ No
Was ihe appGaM 65 years o( aga or more on December 31 af the yaar
� whatwaslhespousa'sageatNaCune
❑ Yes ❑ No ma�ma
Adjusted gross income of appliwn; spouse, and any Source of Inwma Amou'rt of Income
individuals sharing ownership (ForOver65 deduction, income g
may not exceed 525,000; for fhe Over 65 Circud 82akerCredit,
income may nof exceed 530,000 (orindividuals, or 540,000 for S
married couplesj.
TOTAL $ 0.00
t�a yw rded tor am aner am�m,:7 n�..ma� aad��?
� Yes � No
Hava you filed tu deduetioea in any aher wunry? If Yes, what camry?
� Yes ❑ No
IlWe certify under penaity of perjury that the above and foregoing information is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signature d applirant Pdtlress of appGmM (�beraM street, rJty, stale, aMZlPmde)
Signaturea(auU�onz representative tlras ofauthorized remn ' a(num6eraMsfreef,cit};stan,endLPCatle)
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