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APPLICATION FOR SENIOR CITIZEN couNrv TOWNSHIP � YEAR
r�.,n.'4 PROPERTYTAXBENEFITS �
State Fwm 43708 (R9 / 448)
•i Prascn6ed by the Depanmant ot Lacal Govemmerrt Finance
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Informatiom m�tained in this documeni is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.7-35-9.
INSTRUCTIONS:
F I�e�
To be filed in person or by mail wifh the CouiMyAudifor of the county where fhe property is loca(etl. �� n� ZO�t
Filirig Dates: 1) Real Property: DurYrn� the AveNe (12J months be%re December 31 of the ysar the deduction is to be e !i .��
2) Mo6de Homes assessed urMer IC 67.7-7 or manulactured homes irot assessed as real property: Dun�, tf� pC�:�qronths
6e/ore MeiM 31 0/ the yeer the derluction is to be eflective. ` ` V v
aee reverse aae rw aooarone� mswcuons ano v�amrcawru. COUNTY AU V� � v^
Type d beneEt re�uesEed (pl ack a0 fhat appiy)
Over 65 Deduction from Assessed Valuation er 65 Circuit Breaker Credit
Name af epplrcaM (owrrer a can7s Q 1
VV� • `V�
Is aoo���� Ihe sde lepal or eduitable eR If No, what is his�h e act s re w inte�esl? If owned with someona Whar lhan spwise.
inditate vnt� who.m
p-� ❑ No
tt name on record is diRaram Nan Ihat d epofiwnt ��dicate bebw
Nama ol contrac] saller (appfica must hnve beon buyirp m cmtrda af least om (f) yoap �
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Pdaress of mntratl seAar (numb eid abee; city, slafo, aM ZIPmOe) Is �^e D��et�y in CuBStbn:
� Real prope ,ry � Mobile home (IC 6-7-1-�
Taaing dI ' Key numher I Legal dascnpiirn Recwd num6ar Page number
a(v-la-lP l�d-oo13y�T-oa�
Is Ne p pe used and orcuWed primaNy br I Assassed value ot tha properry as ot March t. wr.ent year (may not excee0 Si82,a30
hisrtiar (esiCenca7 hr O�er 65 tloEUrlion, a+S760.000 for Ne Orer 65 CircuR &oaAw Creditj
es ❑ No
Was the eDD��m 65 years of age a more on December 37 ot the year Appliranfs data o( birth (monN, tlay, yoaQ If fileG q� a surviving. u�martied soouse,
pnor to ihe wrterit yeaR �+at was the spouse's age at the time
rn � ❑ No �_ � _�� otdeath?
�j'Y85
Adjusted gross ineome of applicant, spouse, and any Source of ome nmount of Income �
individuals sharing ownership (For Over 65 deductron, income I 5
maynot excsed 525,000; lorthe Over 65 Circuit BreakerCredit,
income may not exceed 530,000Ior individuals, or 540, 00010� I S
married couples). �
TOTAL S 0.00
Have you filed fw afry oLhar Cetluctiona7 If vas, what deductions?
❑ Yes No
Nava you fiied for dedu�iions in eny ather wunry7 If Yes, what counry?
❑ �5 C��
IIWe certify under penaity of perjury that the above and foregoing infortnation is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signaturedlepplicarit Addressofepplitam (numbora�dsWOl.tiry,sfate,eMZlPmde)
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Sgnalu of euUiorizad reD�aseMative Address of eNhaizad ra sentative (num6eraM s'voaf. ary. stale. and LP codo)
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