Age_Berry�
APPLICATION FOR SENIOR CITI2EN
;. -. , PROPERTY TAX BENEFITS
State Fortn 43708 (R9/408)
�, u,. � Prascnbed by ihe Departmetn of Local Caovemmem Finance
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In'ortna[iom m�tainetl in this doament is CONFIDENTIAL pursuant to IC 6-1.7-72-9 antl IC 6�1.1-35-9.
COUNTY TOWNSHIP � YEAR j
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DECal S 2008
INSTRUCTIONS: � /
To 6e filed in person or by mail wifh fhe CountyAudita o(Ne counry where Ilie properry is locafed. �rv�'
Filing Dafes: i) Real Ptoperty: Dunng Me fweNa (72J monNS befoie December 37 0l the year the deduction is to be eBective. ��j( ���SOR
2) Mobile Hanes assessed untler IC 6-7J-7 or manu/actured homes rrot assessed as real pmperfy.� Dunng fhe twelve �7�V'ti���s
befae MarM 37 of the year the deduc6on is to 6e ef/ective. G�gs�� '
See reverse side lw edddional instmdions end qua/ifica6ons.
Typa of beneN renuaSeG (ploam d�eck all �haf aOpM I
� Over 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credit
Name of a plicant (ovmer or contract bv
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' a oNCanl lhe e lepal or e4uitaWa ownaR �at is nisR:er e share o: i-.terest9 It owneE vnih SOmeona othar ISan 6pouse.
indinte wi�h whom
Yes ❑
11 name on recoN is Cifte:ant lhan that ol ao�ican4 ��dicate bebw
Name of mnirsct seller (apqi<eN must Aave becn Duying w. confroct at /easf onc (1) ycaQ
Address of mntred wller (numDarand sbeet, ciry, staro, arM ZIP coda) Is tne omoarry in cuestio�:
Real pmperty ❑ Mobile home (IC 644-�
Tazingdislnc7 Kaynumber/legaldascnotion � ecorCnumSer Paganu7ber .
o�'- /o o?G-dGO - 000. �� �a1
Is the O�OeM used and occuped pnmanly for Assessed valua of tha ompehy as of March 1, cunani year (may nof erceed af82.d3:
his/nar residen�T for OrEi 65 dotluIXiw., w 5f 60.0001or Me Ovai 65 Cirnnt Bmaker CmdiQ
Yes ❑ No
VJas iha appGCam 65 years of age or mwe on Decembar 31 of the year
Mave you fded for arry othar deductionsi If Ves. whal deductiors?
� Yes � No
Nave you (ded tor deEucCOns in any othar courity? If Ves, wnat counry?
� Yes � No
INJe ceRify under penalty of perjury that the above and foregoing information is We and corred and that the applicant was a resident
of Indiana and owner of the a(orementioned property on March 1, 20
Sipnature oi appilcant P-0qress ot aoPlimnt (numberand sWet, ci.y, sfate. and LP wEe)
( �5 S. 7 W� Ow eNSU���� e � 65
natura of uN z reoresemativa Address o( authorizec rea�asentative (numbciand s✓ee:, ci.y, stato, antl LP cotlo)