Age_CreceliusAPPLICATION FOR SENIOR CITIZEN couNn TOWNSHIP � YEAR
. PROPERTY TAX BENEFITS � g � �
�S... =! State Fortn d3708 (R9 / 4-08� � J
u, Prascnbed ty Ihe Depa�tmanl of Lacal GovemmeM Finance
Intortnatiom m�tained in Nis tloament is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
MA��� 1 6 2011
INS7RUCTiONS: C,�J,1v\�
To be (IeC In person or by mail with the CounlyAuditw ol Ne couny where fhe property is locafetl.
Filing Dales: 1) Real Pioperty: Dunng fhe hveNe (12) monfhs 6efae Decem6ei 37 o/the year the deduction is to�yp,efl�4t�v�.OUNT�' UDI�OR
oS
2) Mobile Homes assessed urMer IC 67. 7-7 or manufactured homes rrot assessed as reel property: bunrig �tiie MsNe ( 2 mon s
6e%re March 37 0/ Ne year fhe deduction is fo 6e effoctrve.
See reverse stle fa edd�Tional insLudions ernf Qualifications.
Type d herreEt raaueste0 (Weam rheck a6 Naf eppl�
� Over 65 Deduction from Assessed Valuation �c Over 65 Circuit Breaker Credit
Nama of apd�^� (�+�/ a cart�ecl buyerJ n ,
w . V ��
Is appliant lhe sole I or epuitaMe owne(7 It No, what ia his/ner exact shaea w in�eresil I( owned with someone olhar than spouse,
indiata wit� whom
❑ Yes ❑ No
N name on racord'u difteiem Man thal dappl'i�nt ifMicete bebw
Name d contraa seller (appl�wnt must Aare Deen dryinp an cmvaa a� �exst one (1) yearj
Pdd�ass of contred setler (numbm arM stree4 cily. sfafe, erid ZIP co0e) �5 the pmperry in Quaslion:
� �e-(rl/�.�� � � � � �Real properry ❑ MoDile home QC 64J-�
disirict Kay number / Legal description Record number Page number
�!o -/�-l1l - l0 3-0o a .3 � � -o
Is the O�VeRy used and ocwpied primanly (or 0.ssessed value of Ihe WoDerry as a( Ma�ch 7, wrtam year (may mf arceeE 5182,d30
hiMnar residence9 h�O�er 65 OoOUeim, ar 5160.000 fw f1w Orer 65 Circuit &oekor GetliQ
�Yes ❑ No
Was the eDW��165 yaern ot age or mae on Decem6er 37 of t�e year
Have you (Jed For any dher deductims7 I(ltrs, whai deductions?
�,�5 p Na f! 5, rit
Have you (Jed (or OeEuGwns in any dher wurity? If 19s, whal counry?
� Yes ❑ No
I/VJe certify under penalty of perjury that Ihe above and foregoing information is irue and correct and that ihe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signatura of aOd��M Pddress ot ao0limnt (numbcr a� sfrool. ciy. zaro. aM ZIP mde)
�' ' � aoU3. /e�c�oocl D�. rin Z.���G �
Signatu. W a oAZed reo�esen a Address ol eu�horizad reo�esentative (numberanL s'veet. city, sfate, and ZIP cotle)