Age_Pohl (4)APPLICATION FOR SENIOR CITIZEN %� �
� ;. . PROPERTY TAX BENEFITS 1
S,. •'• State Fortn a3708 (R9l 9-OB) `./
Peescribed by tha Dapartment of local Govemmem Finance
�
�
Infortnation containetl in this dawment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
�NSrRUCnoNS:
� COUNTY TOWNSHIP � YEAR j
� �
Y
DEC 1 7 2008
To be filed in person oi by mail wi(h fhe CountyAUditw o( fhe county where fhe properly is locatetl.
Filirg Dates: 1) Real PropeRy: Dunng the AveNe (72) months 6e/we Decem6er 37 0! the year fhe deduction is�2�e,ef�tec�.y
i
2) Mobile Hwnes assessed under IC 6-7. 7-7 or manNactured bomes rrot assessed as rea! og pe� : During the �(72J monffis
befoie Marrh 31 o(the year the deduc6on is to be eHective. �'� 5 COUNTY AUDI70R
See ieverse sde fir additionel insLVCtions and qualifications.
Tyoe of banef.t reGUaSec (ploaso Neck e0 that app/y)
❑ Over 65 Deductio� from Assessed Valuation Over 65 Circuit Breaker Credit
Nameyj�Qplicam(ownerwconVaclb �� �� �`=�
. �
L/
Is ao�lioM Ihe so!e layal or eCUiWDia ownaR It No, what is nislner eaad snare o: I:deres�7 If owned aith someone ctier Nan soouse.
L�,'ifata wiln wbom
� ❑ No
tt name on recoN is diRerent Ihen thal of ao�wnt inCiwte babw
Name o1 wntad sail :(appFCant must have Oem Evying on cm✓act a; Masf oiro (t) yoa�
Pddress of mntrad se er (numboraM sbeet, crty, stale. aM ZIP cotle) Is iha omoany in ouestion:
� Real properry ❑ Mobile home pC 6J-7-n
ing dislncf , Key nu:n>er / Legal descrio�ion I Record numbar Page number
�(�-I$ -�3-�ao-ool.5o�e-fla5
Is Iha o�OeM useC and occuOieC Ddmanty r Assessed valua of the omperty as of March 1, wr.ani year (may nof axcoetl 5:b2.a30
hislner residenceT lor Orei 65 tloduction. w Sifi0.000 fii th0 Ovo/ 65 Ci2uif &oaker C2tli�
es ❑ No
Was Ne aDD�em 65 yaars of eBe w rtwre m DecamGer 31 of lhe year
Have you (led br a.ry other detluctions? If Ves, •xnat aeductior.s7
�S o N� �
Hava you fied tor ded�ctions in any Whar counry7 If "es, wnal wunry?
� Yes ��
IM/e certi(y under penalty of perjury tha� the above and foregoing information is irue and correcl and lhat the applicant was a residen�
of indiana and owne� of the aforementioned property on March 1, 2D _
SgnatureotaDd�nt AdC�essolao0��nt (numflerands! t,ci.y.sta+e.andZlP.rntle) ^
�0„�2 � �C 8u��s i�sw F �,�R- - �76 � 8
Signatura of auLhonzec reGresentative /+2Cress of auttarizec :?a2ser.utive (numDCr arrd s:recl, ci.y, statc. and ZIP cotle)