Age_WillisAPPLICATION FOR SENIOR CITIZEN couNrr TOWNSHIP vena
; . PROPERTY TAX BENEFITS I
,� �' State Fortn a3708 (R9! 9-OB)
Prescribed by tha Dapartment ot Local GovemmaM Finance
Infortnation eontainetl in this document is CONFIDENTIAL pursuant to IC Gt.t-12-9 and IC 6-7 J35-9. D E L 1 FiIB.A?26k,
7 LUUB
INSTRUCTIONS: � '�j
To be filed in person or by mail with fhe CountyAutlifa o/ the county where the property is loceted. J'� �"' ���
Filing Dafes: 7J RealProperty: Durirg fhe tweNe (72J monNs be/ae December37 of(he year(he deducfio���So���.�Y AUDITOR
2) Mo6ile Homes essessed under IC G7.1-7 ormanu7actured homes rro( assessed es real p�oparly: Dunrg the h.slve (12) months
belore March 31 01 the yeer fhe detluction is to be eHective.
� lr�. nNA'A:��el :r�nlr�.N:nne eM n� ia/iRrelirv�e
TYOe d beneN (BGUeSed (P�eesa d�eck eHl1Wt ePNY�
�Over 65 Deduction hom Assessed Valuation Over 65 Circuit Breaker Credif
Name of aDP��i (awrwv cartrect euye� � •
Is a0olio(rt lhe sde Iegal or eQUita le owne(J If No, what is his a a:e , m � st7 If owned witn somaone other ihan soousa.
/� indicate vA�h wnom
�Yes ❑ No
II nama on recwd is ditFarant Man lhat of aodicanL inOirate hebw
Name W conitEd seAer (apdkant must hare baon Ouyirg on cmVec! at /oast one (1) yoe�
�� Audress d mntrad selier (numEer a� street. city, sfaro, and ZlP mda) �s tae omoerty in cuestion:
� al property ❑ Mobile home (IC 6-7-7-n
7y��9 p m6er/Legal dascnOtion Record num5er Paga number
�
Is the pmperty used anC occupiad o��ry kr Assessed value ol ihe om0erty as ot Ma¢h 5, curtenl year (may nof erceod 5182.d30
hisfner rasidente4 lor O�er 65 doducfion. or Si60.000 (or �ne Over 65 Cilcuit &eake� GeEi�
Yes ❑ No
Was the avd�m 65 yean ot age w mora on December 3t of ihe year
�
Have you filad for a�ry other datluUbns7 If Yes, M�ha� dedvUior.s?
�Yes � No
Have you filetl fm deductions in any other eounry7 If Yes, what county7
� Yes ❑ No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and fhat tha applicant was a resident
of Indiana and owner of the aforementioned propefij on March 1, 20 _
� Sgnatura d eDd�m AtlEress of a00��mr.t (num0erand stroet, dry, staie, and ZIP wde)
�.�,�-� lf/� �"6 Fifi �. Oi �l , �' ` �, . �%� G
Signalure d authorzeC reoresentaWa Address ot autMrizad re��esentative (num6orantl s:roat. ciry, satq antl Z/P code)
0