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Age_Green�
"'"w APPLICATION FOR SENIOR CITIZEN couKiv TOWNSMIP venft
_- . PROPERTY TAX BENEFITS � � �
S�'; State Fortn 43708 (R9 / 4-0e)
un Prawibed by the DepartmeM of Local Govammem Finance
�FEB 1� 2012
Information containetl in Nis doaiment is CONFIDENTWL pursuanl to IC 61.1-12-9 antl IC G1.135-9.
INSTRUCTIONS: C . �, n�
To 6e ned in person or 6y mal wHh fhe CountyAuditw o/ Ihe munty where the property is /ocafetl.
Filiry Dates: i) Real Pioperty: Dunry Ihe IweNe (72) mwrths 6e/ore December 31 olthe yee! the deduction is to 6 Gl6 NC UNTY A1�DITOR
2) Mobile Hanes assessetl urMe� IC 57.1 J or manulactured hanes not assessed as reel propelty: Dunng�twa� (�2) mm3hs
be/oIe Mardr 37 o7the yearfhe deduction is to 6e eflactive.
�
�
li
See reverse side 1or adddional insWctions antl qualificafions.
Typa d benefit requestaE (ploase rheck a0 Naf apply)
.�Over 65 Deduction 6om Assessed Valuation �'6ver 65 Circuil Breaker Credil
NameofappGcanf(ownurarcaNiaGbuye� �
� �
Is applirarrt the mle al or aqvilaWe
H name m reoottl is diHerent Ihan Ihal of epplirant, iMkala belox
Nama o( mntrarl selter (app(rcanf musf haw boen buyirg m cron7act af loast one (7) yeaQ
Pddress d mntraU saller (number aM sbae4 �h. slafe, aM LP wde) Is the pmperty in question:
� Real pmperty � Mobile home (IC &1-1-n
Tazir`g�d� ' Keynumber/Lepaldesuiplion RecoNnumber Paganum6er
7 jt��-c�-t�o-,�.� -/� , i8- ao3 -0o a3 ��- o��'
I5 fha property used end occupied primarily for Assessed value of the proPe(ty az ot Maich 1. �vrterrt year (maY � P+� S1ffi.430
hisThar residenre7 for O�ei 65 deduclim, or f160.000lor Ne Over 65 Cimuf &ealmfCrediQ
❑ Yes ❑ No
Was the appGCar�t 65 yaars of age a mora on Decembar 37 of Iha year
Have you filed tor arry other tleductions4 It 19s. wnat dedutlions7
� Yes ❑ No F{" 5 � /''�t
Have you fJeE ta deduc6oris in any other county? If 16s. what mu�rty?
❑ Yes ❑ No
VWe certify under penalry of perjury lhat the above and foregoing infortnadon is true and cortect and thaf the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signatureotapplinnt PdOrassotapplimnt (^�DeranOSboal,city,stafe,andZlPmde)
/.2 y S. G.so,U .4/ c�7a.c/ %tI 76 d
Signatura arfzedrep�esantativa AEdressofaNhorimtlrepresantativa (nvnberarMSLee4�'.��. tlLPcotle)