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Age_Hurstrs_'" APPLICATION FOR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
State Fortn 43708 (R9 / 9-08)
•O r Presaibed by �he Departmam of Local Go�emmaM Finance
Informatiom m�tained in lhis dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC E7.1-35-9.
COUN7Y TOWNSHIP YEAR
File Mark
lNSTRUCTIONS:
To 6e fdetl in person or by mail with the CountyAudifor o! the wunty where fhe property is located.
Filirg Dates: i) Real Property: Ounng the (weNe (12) months 6e(ore Decem6er 31 0l the yea� the deduc0on is to be eflectiva.
2) Mobrle Hanes assessed under IC G7.7-7 or manu/ac[ured homes rrot assessed as real proper(y Dunrg (he hveNe (72) mmfhs
be/ore Marrh 37 of the year the tleducfion is lo be eflective.
See ieverse sitle Ipr additional instrudions aiM 9ualiflcafions
TyPa of benef.t �e0uasted �please rhec/c aH Nat appl�
❑ Over 65 Deduction from Assessed Valuation ❑ Over 65 Circuit Breake Cre i
Name a( a0d"rarit (owriar or cronfracf AuYsrJ
I G'�.M
��
IsappGoMlhesdelagalorequitaW HNO,whatishis�herexadsharewinierest? Gig i������ ��pt+sao��.
es ❑ No
If name on recoN is diRaram than that of appfi�znt �ndiwte bebw
Nama of mntad se0er (app�rt:ant mvst have been Duy'ug m canf2ct at kasf one (1J yra�
AtlEress ot mnbad mllar (num6or antl straef, city, s61e, a�d ZIP mde) Is ihe pm fty in Question:
Real pmperty � Mobile home (IC &74-�
Taxi�g d'atrid Key number / Legal descnption Record number Page number
� � a _ - g-��. .�r�-o��
Is Ihe popeM �� aM accupieE pnmariy (or Assessed vaNe o! Ihe p(operry as of Marrh 1, wrteM yaar (may not rsmed 5782,430
his/her rasidenwT lorOrer 65 tleCUdian, or Ef 60,DOO IorNO Ovrf 65 Ciicwl Breaker CrediQ
❑ Yes ❑ No
Was Ure appf�m 65 yean of aga or mora on Decembar 31 of Ne year
of daafh7
Adjusted gross income of applicanf, spouse, and any ource of Income Amou,rt oi Incoma
individuals sharing ownership (ForOver 65 deduction, income $�
may not exceed $25,000; (or the Over 65 Circuif 82aker Credit,
intome may rrot ezceed $30, 000 fo� individuals, or 540, 000 (or $
married couples).
TOTAL $ 0.00
F1ave you filed for any other deductions7 H Yes, whal ded�x]ions7
❑ Yes � No
Hava yw filed tn dedudions in any othar courity7 If �4s. what couMy4
❑ Yes ❑ No
IlWe certify under penalty of perjury that the above and foiegoing information is We and correct and that lhe applicant was a resident
of Indiana and owner of tha aforementioned property on March 1, 20 _
Signalu�a d appficam Address of appGCant (manber aM sbaef, dty. sfale, aM ZIP mde) n
(..� $ O O N% v�LJ ? �J
S n �eo(authonzedre rese ative AddressofaulhorimEraprasentative (numberarHStleef,cdy,stato, dZ/PCOdo)