Age_ONeal (3)� ` "' APPLICATION FOR SENIOR CITIZEN
= ' PROPERTY TAX BENEFITS
S-�' State Fwm 43708 (R9l 9-OB)
Prescn6ed hy �he DaDartment of Local Govemmant Finance
G�
Information contained in this tloament is CONfIDENT�AL WrsuaN to IC 6-1.1-72-9 and IC 6-'I.1-35-9.
INSTRUCTIONS: � D E C 1
To 6e filed in person or 6y mail with the CountyAuditor olthe wunry where the property is located. 1 8 2008
Filing Dates: 1) Real PiopeAy: Dunng the hveNe (72J months before December 37 07 fhe year the deduction is to be eflective_
2) Mo6ile Hwnes assessed under IC 61.1-7 ormanWactured hanes rrot assessed as real pmperty: Dun�•� �Ne.Fl2�nontlis
be/ae March 3 f o! the year the deduction is to be eHecWe. �6S �a �
SeereversesidefaatldNOnalinsWCtionsaMqualifications. C'�BSON COVpJTY U 17pR
Type d baneft �eGUaSed (ploesa diech e0 thaf appty) �
❑ Ove� 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credit
Name
e��o�
Is a071ifartl the sole lepal or eQUitabl¢ owneR �7d. �'+at is hisRier exact shara or interest7
❑ Yes ❑ No v
I( name on record Is diflaren� ihan that ot ao�ca�t �ndicate belav
Name N contaq saller (apdkenl musf haw 5ern buyirg m cm✓act al loast o�ro (�) Yca�
sble, and Z/P mde)
Is ihe property used and occupied pnmany br
hisRier residenw7 '
, ❑ Yes ❑ No
Was the aDp�mm 65 years of aga or mora on Decem6er 31 of tie year
pti0r ta MB arrent y08(1
� Yes ❑ No
I Adjusted gross income of applicant, spouse, and any
individuals sharing ownership (FOrOver 65 deducfion, income
may not exceed 525,000: for the Ovar 65 Circuit Bieaker Credit,
income may not exceed 530,000 for individuals, or 540,000 for
married couples).
Have you
Have you fled
any olher dedudions7
�s
deduclions in any other couniy)
� Yes
ihan soouse.
I Is ine �moerry in cuestioa:
� Real propery � Mobile home (IC 6-i-7-n
riion I Racord numcer Paga numbar
� ("L��IJ •D Ol /'K�
� Pssessed value of the o�ooa%1y as of March 1, curtant year (may not ezcectl 5i82,d30
(or Owr 65 daductim, w 5760.000 lor fho Ovcr 65 Circuil &eaker CrtNi�
�
II/We certi(y under penalty o( perjury that the aoove and foregoing in(ormation is true and correct and lhat the applicant was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20
� SgnaturadaoP�cao1 Atld:essotaOD��mnt (nomGerandsheet,ci,y.staro.antlZlPCOdo)
_ r�
�
diepresentaGve
of
(r.umter antl s1me1, ciry. 9afc, an0 ZIPCOOC)