Age_Lindsey� APPLICATION FOR SENIOR CITIZEN courm rena
PROPERTYTAXBENEFITS .' ;! �
� Sfate Form 43708 (R9 / 9-0B) ^ � �
•O � Prescnbed try the Oepartmerit ot Local Go�emmeM Flnance �p
Informatiom m�tained in this document is CONFIDENTWL pursuant fn IC 61.1-12-9 and IC 61.1359. �[:,� 3 'C�r�ark
INSTRUCTIONS: C�''n " V .
To 6e fi/ed in person or 6y mail wifh the CountyAuddor o/ the munty where the pioperty is located.
Filirry Dafes: 1J Rea/ Property: Dunng Gie tweNe (12) months be/ae December 31 0/ the ysar the deducf�'oro$�f�e(qQpd0i3Y AUD170R
2) Mobile Homes assessed unOer IC fi1.1-7 or manufactured homes not assessed as reel property: Durimg the MeNe (72) months
6e/ae March 37 0/ the year fhe deduction is to be e/tective.
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See ieverse side for additional instfudioru antl qualifications.
Typa d benef,� (equested �please Mac/c a0 Nat appty) �
� Over 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credit
Name of apd�M (�� a' ���� 6uye�
Ls applimm tha sde legal or eQUitaMa ame(! H No, what is hisiher exact s erest7 H avned with sansone oiher than spaum,
iMimte wiN whom
❑ Yes ❑ No
tl riame on remrtf a ditfarenl ihan Uiat o(aOP�nt, indicate babw
Nama d mrtraf3 seAar (app�icant must hare 6een buying m cmt2d at Mast orre (1J yuarJ
Addrass d mntratl mller (numbor arid sbee4 cily, sfak, ariC LP cotle) Is the pmperty in question:
eal property � Mobile home QC 614-n
T�i�gd' riq Keynumber/Lepaldesuiplion RecoNnumber Paganumber
�� a�-�a-v-�-Zal 000�v o
Is Ihe propeM used and orLUpaE phmarily (or Pssassed valua of Ihe pmPe(ty as of Maml� 7. airte'rt year (maY ^� e+�� SiH2.430
hisrher �esiCenm? for Ooei 65 dedudim, � Ef60,0001or Ne Over 65 C'vai! Brealmr CrediQ
� Yes ❑ No
Was tha appGfan165 years ot age or more on Oecember 31 of the year
Have you filaA tor any other deEuclionsT N Yes. what daduGions?
� Yes � No
Hava you filatl (or dedudions in any olner cwnly? If Ns. whal murrty?
� Yes ❑ No
IIWe certify under panalty of perjury that the above and foregoing infortna[ion is We and correcl and that the applicant was a resident
of Indiana and owner of the aforementioned properly on March i, 20 _
Signaluredappruant AddressafaPV�m (numberaMstroeL�'�Y.��.aMZlPmde)
-a. - �,' J _ _ �-- �
naturedaWharaetlre antalNe ACtlressotauthmized2premntaWa (numbera tity,sGfe,andLPCade)