Age_YoungAPPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
� S �'! State Fortn 43708 (R9 / 598�
Prescnbed by the Depertment of Lacel Go�emmem Finarica
�
Infwmation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC &1.135-9.
INSTRUCTIONS:
To be filedln person or by mail with Ure CountyAudRa o/ fhe county where the propeRy is located. �� 1 C���9
F7irg Dafes: 7) Real Property: Duriry the hveNe (72) mwRhs belwe Oecem6er 37 olfhe year fhe deduction is to be e e 1�
2) Mobile Hames essessed untler IC 6-7. f-7 or manufacturad homes rmt assessed es real propeRy: Ounng Ne tweNe (72,/) months
belwe Marrh 37 0/ Ne year Ure deducfion is to 6e ef/ective. �p� ��
See raverse siCe la edditional insVUdions eiM quelifications. O_. ,�% „��
ryve W benefi� reGUapad (deaso tliocx eA lhaf ePP� .
�
Over 65 Deduction hom Assessed Valuation
Name d aoP��wr� ( mor a tmf�acl Duyah
p,p.��i�f �
�� � �
is apor�m tne sae iegai or eQUaaae wme If o, wiwt iy hisRier eaaC share w
❑ Yes ❑ No
tt name on record is diRereM Nan Nal of eDMranL indicata below
Tax4re
coniraa setler (app'icant must have Ocon D�ying m cmvaa at bau om (t) yaa�
of mntrad sellar (numba aM streal, ciy, sfale, aM Z/P co0e)
-ia-o�
.w. ~�..�. �Yes ❑ No
Was �ha eOW�wwn165 yeen o( age w more on December 31 of the year
prior to ihe artant yeeR
�Yes ❑ No
T'
AdJusted gross income of appliwnR BPouse, and any
individuals aharing ownership (FOr Over 65 deduction, inoome
may not exceed 525,000; for fhe Over 65 Circuit Breaker Credit,
i�ome may rrot exceed 530, 000 for individuals, or 540, 000 fw ,
married couples).
filedbra�ryothardaductions9 r
' ❑��Yes ❑ No
for dadutlions in any other courrty?
� Yes ❑ No
65 Circuit Breaker Credit
t( owned wiih wmeone Wher ihan srouse.
intlicate with whom
Is the pm�erry in uuas�bn:
Real property � Mobile home (IC 6-74-�
Record number Page r.umber
.000 O(oS'-6 . S
Assessed value of the prooeM as of Maich 7, wrreM year (may not ercead S�B2,a30
!or Orer 65 CeUUGim. or 5760.000 tor Ne Owr 65 Circuil &eaker Cmd�
��
IIWe certify under penalty of perjury that the above and foregoing information is tiue and cortect and that lhe applicant was a resident
of Indiana and owner of lhe aforementioned prop�rty on March 1, 20 _
a aod'xem dIB39 O� Bppllmn� (nuTbM elltl dbOBl, Clly, Sf3f0. d�d Z/P LOdB)
�// � O ir r• E✓/'� N S
(/�.. 'l�(�1NC�rON 47G7o
af euthwizeE rep�aseM e Addass oi aWlrorizad re2�esentativa (numberaM sLeef. city, 5lale. antl LPcode)