Age_MasonAPPLICATION FOR SENIOR CITIZEN courm rowNSHia r�
r _.,.•`!� PROPERTY TAX BENEFITS � �
State Form 43708 (R9 / 9-08)
� Prawibed by ihe DepaRmeM ot Local GovammeM Fnance
1Fle Mark
Infortnation contained in Nis tloaiment is CONFIDENTIAL pursuant to IC 61.1-72-9 antl IC 61.1-35-9. APR j� 1 2012
INSTRUCTIONS: C �
To be filed in persar or by mail with the CountyAuditor of the county where fhe property is located.
Filirry Dafes: 1) Real Pioperty: Dunrn� the hveNe (72) mmths 6e/ae Oecem6er 31 0l fhe yea� the deducfip(t Cfon bye e�fl�ecfive.
2) Mobile Hanes assessed under IC 51.7-7 or manWactured hanes rrot assessed as real prVO��lf�'uumtg�Fiis�Pj�ths
.�
11 I
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be(we Marrh 37 of the year fhe deQuction is to 6e eReclive.
See reverse side ta addilional insVUdions and qualifications.
Type of baneft reduested Iplease rheck a➢ Ihat apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Nartre d e (mmr,r w corrtracf Ouyr+Q
Is app5am Itie sole lepal or e ownal? 0. whal is hisR�er axad share or interest7 II owned with mmeane ofher ihan spoum,
indimte with wtwm
❑ Yes ❑ No
If nama on recad is ditfarent �han Cut d appri�nt inditata bebw
Name of conla�t se0er (appfrcanf musf hare been b�ry'ug on cmtracf af bast one (7) yearj
Pddress d mntrad salier (nam0or eM sbaef, city, sble, eM LP m0e) �s ihe property in Question:
Real property � Mobile home (fC fi14-n
datnG Kay number/ Lepal dasuipcbn Recmd number Paga number
��- a- e� o�- .G93-o��
Is the p�opefty used aM occupieC primarity br Assessed value of lhe proPe(ty as of Mamh 7, wrtaM year (may rwt ermed E7ffi,430
hisTher resitlencel �or O�er 65 detl�dini, d E760 000 for (he Ovor 65 Ci�coit &ealarCred�q
❑ Yes ❑ No
Was Ihe appGan165 y¢ars of epe or mwa on Decembar 37 W Lhe year
Have yw filatl tor airy olher deduUbns7 It Ves. what ded�ctions7
� Yes � No
Hava you fJatl Fw deduclions in any dher couMy? I( Ms, what couMy?
� Yes ❑ No
IIN/e certify under penalty of perjury lhat the above and foregoing information is true and conect and that ihe applicanl was a resident
o( Indiana and owner o( lhe aforementioned property on March 1, 20
�Sign we of a0d��� Address of aPPlimnl (numDer and L aty. sblu. aM ZIP mdo)
1 . l x D , ��7�
Signatu'e d auNOrizeil v ��a�+�'e Pddress of auNOr'rmd rep�esentative (numLer sLee4 Wl: �4 end ZIP cade)