Age_ScottAPPLICATION FOR SENIOR CITIZEN
1 PROPERTY TAX BENEFITS
` -' StaOe Fmm 43708 (R919-08)
� Prescribed by Me Depanmern ol Local Goeemmam Finance
Infortnetiom m�taineC in Nis dowmenl is CONFIDENTIAL W rsuant W IC 6-1.1-72-9 and IC G7.135-9.
��
,�
��F�?�
I' ,, ����
I.
� �• . :��.i
INSTRUCTiONS: —yp /J[!,.
To be filed in person or by meil wiM Ure CourrtyAUd'Ra o! the oounty wheie tlie property is locatetl. // �r � h' �+ ��.
Filing Dates: 7) Real Pioperty: Dunrg Ne hveAre (12) mwrths belae Oecember 37 olthe yaar fhe deducU�q�g� �R�jY AUDITOR
2) Mo6Ne Homes essessed urnler IC �7.1-7 or manu/ectured homes rwf assessed es reel property.� Dunng Ure hveNe (12) months
6e/ore March 37 0! the year the deduction is to be eflective.
See reverse side /or atlUi[ional insWdions arM qua/ificatlons.
TyGa d befrefit re4ueste0 (Wease Mack e9 Nal apply)
�Over 65 Deduction 6om Assessed Valuation �Over 65 Circuil Breaker Credil
Name d eOWinrit (rnnrer ar canhacf Dye9
�'
la epplicaM t�e sde lepal or eQUitable wmeYl If No, what is hisRiar exad share or irteresll tl ovmed with someone olher Ihan spouse.
indimta with wliom
❑ Yes ❑ No
M riame an remrd is ditfarerit than Ihet d epqicant iMicata bebw
Name d cantna saoer (appicant must hxve oeon drying m caruaa at roast orw (f) yea�
AEdresa of mntrari seper (numDer end abeel. cify, stele. eM ZIP oode) �s tna proPetty in duesl'an:
� Real property � Mobile home (IC 6-14-�
Taxl 'ind` Keynumber/Legeldeacription Recordnumber Pagenumber
-/d _o�-io/- ooa, 5�6 - ag
U the propeM used anC occupiad primanly br Assessed value of the prooarry as of March 1, wrtent year (may rwf erceed Sf B2.430
ho�her resMence7 Poi O�er 65 dedudion. a S f 60.000 for Ne Over 65 Circuit &oeker CredrQ
� Yes ❑ No
VJaa the epDlkeM 65 yeare of age or more on Decamber 31 W the year .
Have you filed (or a�ry oihar deductiana7 If Yes, what deductionst
Yes ❑ No �,5�
Have you lleE tor deductions in any other county7 �� �bs, what county?
� Yes ❑ No
I/We ceAify �nder penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
S�gne�ure w eocrcam ndaresa ot aoa�m (m�mber aiM sbee4 ciry. state, and ZIP cotle)
i � y
��.'u� .�-ca-Z�: . /` J�� / liU, O�iC �.P/.G'l'c'T�" . /.0 �% - D
S�pnalure ot ainhorized reoreaemaWe Mdresa of euthonzed representativa (numOeraM sLOet. city, sfate. and LP caCa)