Age_Miller (3)� APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
Sta� Fwm 43708 (R9 / 9-08)
��.� � Piasaibed by Me Departmem of Local Govemmem Finance
Irt;ormation contained in t�is dowment is CONFIDEN7IAL pursuant to IC 6-1.1-12-9 and IC Cr1.1-35-9.
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COUNTY TOWNSHIP I Y� I
FI ED
MAR 0 3 F����iark
lNSTRUCT70NS: C.�J.n ' V
To be fi/etl in person or 6y mail with the CounfyAud"Ra o/ Ne �unty where fhe properly is locaietl.
Filirg Dates: 1) Real Pioperly: Dunrg the tweNe (12) monfhs 6e/ore December 37 o/the ysar the deduc���+���(e{ AUDITOR
2) Moblle Homes assessed urMer IC G7.7-7 ormenulacture0 homes rrot assessed as real property: Dunlg the fweNe (12) months
6e(ore March 31 0/ the yea� the tleduction is to 6e elfective.
See reverse side for adCdional insUUUions end quelificafions.
rype W beneft rapuepetl (pleasa diack aB fhat appl�
�Over 65 Deduction from Assessed Valuation �ver 65 Circuit Breaker Credit
Nameda ircanl(owna�orcan4acfWyeQ ,
la aOP�itanl ihe sole iepal or eQUitade axnaR NO, WFId� 19 (IISRIBf BY2C� 8hdfB Of IfIlB(BSIT tt ovmed with mmeona Wher than spouse,
IlIdICd�B Wli�l M'h0lf1
❑ Yes ❑ No
H name on record is Oifle�em Man that d epp6mnt ��diceie bebw
Name of contract seAer (epp�icenf mvst hava bean b�ryirg on cmtract af lesst orre (i) yeaQ
Address of mntrad aeller (num0or aM sbeet, cdy, sbfe, and 21PcoEe) Is �he pmoat�y in aue5iion:
�eal property � Mobile home (IC 6-f-7-�
Taaing di at Key number / Legal dascnptian — Reca�d numCer Page num6er
-za y -c�a , g
Is the p(ooeM � end occuped pnmariy br AssesseE value ot Ihe prooefty as ot Mamh 1, curzam year (may rrof erceetl 5 t82,a30
hisThar residenm? lor Uer 65 tleductian. a 5160.000 (or Na Ovtv 65 Circ�i( Breaker Gadin
� Yes ❑ No
Was tha epplicaM 65 yean of age w rtrore on December 31 of ihe year MO����'s data o( birth (morY,h, day, yeaQ If filed by a surv'rving, un.ma .r,ec soouse,
Pf10f �0 �:IB alRBll� YBi�i wha� was ihe spouse's age at �he tMe
�,�s ❑ Na - 7- 3 � o�d��,�
Adjusted groas ineome of applicant, spouse, and any
I
Hava you filed fw erry dher EeEucUOns7 �1 Ws, wnat deauctions?
Q Yes � No �. S �
Have you filed fv OeOudions in any other cou'rty7 If �6s, what courtry?
❑ Yes � No
u
IIVJe certify under penalty ot perjury that the above and foregoing information is true and correct and that lhe applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20
SignatureMaodiram Mdressotepplitant (numboraMsbaet,ciy,sWte.aM2/Pmde)
f. �� 5�/Z /��-�—�—�--"'— I�.ti.�-�u�.—, �,v s<7�
Signature W authorize0 repreaentative Address oi eWhmizeE representalive (numberand s' , city, stafe. and Z/P cotle)