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.0"'''a APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
"1 PROPERTY TAX BENEFITS
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'`. Stale Form 43708(R16/1-23) 1 —Nr3V) Oz ---- ZoLI
M6 Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS: To be filed in person or by mail with the county auditor of the county where the property is located.
Yes 0 No (� •
Have You Filed for D ction in Any Other C n ? If Yes,W t County?
❑Yes No
I/We certify under penalty of perjury th t t e above and foregoing information is true and correct.
Signature of Applicant Date(month,day,year)
4 C,f nag/L- , (71&tc P074) /1-og-a q
Address of Applicant(number and street,city,state,and ZIP code)
{CS7 Est 6 C
Signature of Authorized Representative 1 i Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Sire of County itor P0 'zieDate(m nth, a r)
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DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer °,b =.
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