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APPLICATION FOR SENIOR CITIZEN
4 PROPERTY TAX BENEFITS
�S Slate Form 45708 (R919-08)
� Prascnbed by Iha Deparimen� ot local Govemment Finance
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Information oontainetl in this tloament is CONFIDEN7IAL pursuant to IC 6-1.7-72-9 and IC 67.L35-9.
COUNTY TOWNSHIP � YEAR
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ile M�
�NSrRUCnoNS: pEC 3 1 20�8
To be filetl in person or by mail with fhe CountyAuditor o7 the counry vfiere Ihe poperty is /ocafed. •
Filirq Dates: iJ Real P�operty: Dunng the fweNe (12J months before December 31 0! Ihe year ihe deducfion is (o be eNecfive. //�/
2) Mobrle Homes assessed urMer IC 6-7. i-7 ormanWactured homes not assessed es raal pmperty: Dunng�liie2vgNa �Y2ril(aitfis
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be(we March 37 of fhe year fhe deducGOn is to be eNective. N�Y AUB�fi��
See reverse side la atltlifionel insLUdions arM qualifications. �I�g�N C'au
Type of benef.t repuesbd (daaso dwck a� Nal appyj
Name
ver 65 Deduction from Assessed Valuation
,.: cmlreCf DuyoQ
or eQUitaWe owneR
❑ Yes ❑ No
II name w racord is diflerent Wn that ol aod��4
Neme of mnt2ct saller (epplican! must haw
If No, what is �isfner exact share or
m conbacf at least orro (1) yeaQ
of contrad saller (numDwaM sWO(. cM. sfam, arM ZIP wCO)
accupiea
�Yes ❑ No
aga ar mwa on Decembar 31 d Ihe year
�Yes ❑ No
Adjusted gross income of appliwn� spouse, and any
individuals sharing ownership (For Over 65 deduction, income
may not exceed 525,000; 7or fhe Over 65 Circuit Breake� C�edit,
income may rrof exceed 530, 000 7or individuals. or 540, 000 for
manied couples).
Have youlilad tar any Mhar detluUans7
Yes
you fleE tv Eadvc4ons in any othar munry7
. � Yes
� No
No
Over 65 Circuit Breaker Credit
�r/ � i/�
If ownaC with wmeone other Ihan spouse.
ir.Cinte with whom
is me orooany �� cuesi�o�:
� Real propery � �dobile home (IC 6-7-7-n
INJe certi(y under panalty o( 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, 2� �
W aod�nt
of applimr.t (numberar.d sVCCI, d.y. sfate. and ZIP coEC)
� . �[ J� � S-S/'l �� �/�C � � �
gnature authonzed raDresenta e MOress of aulhrnizeC reo:eseniabve (r.umbcr antl s:rcel. ciry. 9atc. and ZIP code)