Age_Hartley9
' a APPLICATION FOR SENIOR CITI2EN 1' COUNTY � TOWNSHIP � YEAR
,. . PROPERTY TAX BENEFITS � �
•� `-�• State Fortn 43708 (R9I9-OB) ��
� Prascnbed 6y tha Oapartment ol Local Govemment Financa
Infwmatiom m�tainad in Ihis tloament is CONFIDENTIAL pursuant to IC G7.7-12-9 and IC 6-1.Y35-9. �. ��
INSTRUCTIONS: ��� �1�0�
To be filed in persm or by mail witA Ne CountyAUditw of tAe county whera the property is located. `��� q���
Filing Detes: 1) Reel PropeRy: Dudrg fhe hveAre (12J months 6e/ore December 31 o/the yearthe deduc( n is to bQ-@pective.
2) Mobile Homes essessed under IC 6-7.7-7 ormenulactured hwnes not assessed as real property: Ounng fhe hveN@d{� �onft�q]�''
belore March 37 0! the year the deduction is to 6e eHective. _i3O'! 6' iT � iy hv�`
See reverse side Iwetldifional insWClions aiM qualifications. 0�_nVH
Type d bereN
/` ` F
e
65 Deduclion 6om Assessed Valuation
If No, what ia hisfnar
� Y� u �,o �
It name m rew�d is EiAerent Nan that of apd�n� indiwte 6ebw
Name of cor.tae sailar (apptitant must haw Dem Guyilg a+� cmvact at basf one (1) yoa�
contraG w0er (numberaM sbeet. tify, sfale, and ZIP cotlo) r
Tazing distnct
I5 tha prooeM used and occuDied O�mardy br
nismar eesden�t
� Yes ❑ No
Was the xoo���165 years of age or mora on Decembar 31 of Ine year
o�or to Ne arrent yea(7
❑ Ye5 o No
Adjusted gross ineome of appliwnR spouse, and any
individuals sharing ownership (ForOver 65 deduction, income
mey not exceed 525,000; Ior the Over 65 Circuif Breaker Credit,
income may not exceed 530,000 for individuals, or 540,000 for
manied couples).
Hava you filad for any
� Yes
fled fw EeEUCUOns in any other tounty7
� Yes
� No
� No
Over 65 Circuit Breaker Credil
w ir.tetest'!
� witn somaona other than spousa,
wi�h vhom
IS �hB D�O�atty in
Real propery � Mobile home (IC 6-7-7-n
rnrr ��moer Paaer.um5er
the pmpe:ty as of March 1, cuRent year (may nol ercoed
ion. w 5160.000IOr the Ovoi 65 Cirt�'r: &eaker GoGit)
�, 3or
INVe certify under penalty of perjury that the above and (oregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
gnatura of apdwem � Pddress of aoPlicarf (number ar.d swet, ary. s(aro, arrd ZIP mae)
%�Cln/u� �. �G�
Signature d a orizad reo�asentativa
Si8 � � --r- � .� ,���
AEErass ol authorized reoresentativa (numCa nd slieet, ciry, Aaro. and ZIP codo)