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� APPLICATION FOR SENIOR CITIZEN
r . . - . PROPERTY TAX BENEFITS
S-'' Sfate Fwm 43708 (R9 / 4-08)
� PrescAbed by Ihe �eparimerrt of Locel Govemmenl Finance '
Informatam m�tained in this document is CONFIDENTIAL Wrsuant to IC 6-1.1-12-9 and IC G7.1-35-9.
!G�F9CiIlNlZi7`i6Y�
COUNN TOWNSHIP � YEAR
FI�`�D
To be filed in person or by mail wit/r fhe CountyAudifa o/ the county where the properly is located. I�,I(� 1 C � Ol U
Filing Dates: 1) Reel Property: Dudng tAe fweNe (72J months 6e/ae Decem6er 37 of the year the deduction is to be s//ACNi%1 1 V
2) Mobde Homes assessed urMer IC 6-1.1-7 ormanulactured homes not assessed as real proper(y: Dunng the hveNe (72) months
6xfore Mardi 31 0l fhe vear the deduction is to 6e effective.
m � v
See reverse sitle !w adddional insWdions arM qualifications. Q�!� N��
Type of henefit repue�iad (please d+eck a➢ (hat appy� �
Ovar 65 Deduction 6om Assessed Valuation �Over 65 Circuit Breaker Credit -
7T
Name of apo���i (oMner w con6act Wye�
Q
is aoo�iam tne soie iegai or eo��ae ovmen If No, what is nis�Ter ezact shara or interesl9 If owned with wmaone othar than spouse,
indinta vnth whom
Yes ❑ No
If name on recorti is dMe�eM Man that d applifanl, indicale below .
Name ot conirzcl saller (applicant musf have beon Ouyilp7 on conflact at leasf one (1) yea�
Address ot contraG seller (numbaa� sbeef, cily, slate, and ZIP mCe) �s the O�DeM �n puestion:
Real pmperty ❑ Mobile home QC 6-1-f-�
� Taxin dislncl Kay num6er / Lagal descnption Recortl number Page number
� o� �=3i- ._aa�i
Is Ihe O�GeM used a'W occuoiad pnmariy for Assessed value of lhe D�verty as of Ma¢h 7, curran� year (may nof exceed St82,430
his/nsr residenm9 !or O�er 65 deduction, w Si60.000Ior Ne Over 65 Ciicuit &eaker CiediQ
❑ Yes ❑ No
YVas iha epplicaM 65 yea�s of a8e or rtrore on December 37 of the year
I
Have you (led kr airy othar deducUOns9 It Yes, wha� deductions?
� Yes ❑ No N � . _
Have you filed for deductions in any other murrty7 If Yes, what county?
❑ Yes No / .,� ��
�-(J
i/We certify under penalty of perjury that the above and foregoing infortnation is true and covect and that the applicant was a resident
of �ndiana and owner of the atorementioned property on March 1, 20 - �
Si9nature N aoWiwm Address ot eODlirent (number and sheel. ciy, sfate, antl Z/P code)
�` ���n� � ��z �,/, f3�oA� wr� y sr
� Signature of auttiwized repres e Mdress o( euthonzad reo�eseo�ative (numberantl sveeq city, stafe, antl ZlP coEe)