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APPLICATION FOR SENIOR CITIZEN
- . PROPERTY TAX BENEFITS
S �', SfaOe Fortn 43708 (R9 / 9-08)
� Prascribed by the Deparimerit ol Lacal Govemmerit Finance
Infortnation wntafned in this doCUment is CONFIDENTIAL pursuan� W IC &1.1-12-9 and IC 61.1-35-9.
COUNTY TOWNSHIP YEAR
� 0. �I� �
uvo �n��.n�rvo:
To be filed in person or by meil wifh the CouMyAutlitw o! the wunty where the property is locafed. �O �� U�U
FNiry Dates: fJ Reel Pmperty: Dunng the fweNe (72) mmNs 6e/ae Oecember 31 o/the year the deduction is fo be
2J MobHe Homes assessed urMer IC 67. iJ or manulactured homes rrot assessed as real property: Dunig the twaNe (12) montl+s
6e/ae MaiM 3f o/ Ne yeer the deduction is to be eflective. `Yr�� —
See reverse sitle /or add3ional insWCfions an0 qualificefions. ��� �, �,���„6
TYDa d beneN reauesfed (deaze Mack a0 Nal appl�
�Over 65 Deduction from Assessed Valuation
Yes ❑ No
If No.
H nama on reco�d is diflarem than that d epplicant, iMiceta bebw
Name of contrzcl
Is �he
�Over 65 Circuit Breaker Credil
'/�I O
�/u- �S
shara w interest? If owned with someane oiher than 50ouse.
indipte with wtwm
Euyirg on cantraCt ef loa5 orro (7) yearj
of mntratl seller (numbw aM abaet, crty, stato, eM ZIP code)
e'W occuped
-ia i
Yes ❑ No
of age w mwe on December 37 of the year
�Yes ❑No
Adjusted gross income of appliwnt, spouse, and any
individuals sharing ownership (FOr Ove� 65 deduction, inmme
may not exceed 525, 000; for the Over 65 Circuif Bieake� Credit,
income may rrof exceed 530, 000 for individuals, or 540,000 !w
manied couples).
Have you filed M arry ofher deCUCUOna7
� Y85
Have you fled fw deducCOru in eny olher cwMy7
❑ Yes
❑ No
� No
erry in ouestian:
Real property � Mobile �ome (IC 6-14-n
/O�-UO3. OGG
Asseued value of the omoerty as of Marfb 7, wrrent year
for Uer 65 daduwon, or 5160.000 for Ne Ovoi 65 Circuit i
Page numDer
Ifl§s,whatdeductions?
I( lgs, what counry?
UWe certify under penalty of perjury thal the above and foregoing information is Irue and correct and that the applicant was a �esident
of Indiana and owner of the aforementioned property on March 1, 20 _
nedresa ot eooii�m (��e�. �d saoa�, rary::r�re, a�d zia ooee�
ol eulhorixad represenUtive
�
svcet, ciry, state. antl