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APPLICATION FOR SENIOR CITIZEN courm TOWNSMIP rEaa
,-- t PROPERTY TAX BENEFITS � �
Slata Form 43708 (R919-08)
�O � Prasrsihed by ihe Departmerrt ot Loral Go�emmeM Finance
Fle Mark
Infwmation containetl in Nis doament is CONFIDENTIAL pursuant to IC G1.1-12-9 and IC 61.'135-9. �C T 2 9 Z� � 9
L
INSTftUCT10NS L _ � �
To be filed in persm or 6y mail with the CountyAUtlifor o! the munty wheie the poperty is locatetl.
Filing Dates: 1J Real Property: Dunng the tweNe (12) montfis before December 31 o(the year (he deduction is�b @ffective.
2) Mobile Homes assessed under IC 6-7.1-7 oi manu7acturetl hanes no( assessed as real property.d�nry �e ��Ne�(12�mon'�si
be/ore Mamh 37 0! Ihe year the detluctlon is (o be eliective.
Sea reverse side 7ar edtldional insVUCtions eiM qualifications
Type of baneft iequa5atl (p�eam rheck all fhat apply)
Over 65 Deduction from Assessed Valuation er 65 Circuit Breaker Credit
Nama of appliram /ownar w canfracf A�yer)
/
f �. �%Q
� (,(iyL�J�
b I�r�t Ue agal or equilable owne(1 N No, whaf u hisrtier xad share or interest7 if owned v�th mmama othar than spouse.
indicate wi�h whom
❑ Yes ❑ No
If name on recpd'¢ diRarerit Ihan that dapplirant indi�ate bebw
Name ot cnil�ad seller (app(ICanf must have 6oen b�rying on canfracf al lea9 orro (iJ yea�
Pddrass of mntrad w0er (numbal arM street, cily, sfa(e. and LP cvEO) Is lhe P rtY in Guestion:
Real property � Mobile home (/C 6-1-1-�
7ay� {�t Keynumber/Legaldesuipfion Recortlnumber Pagenumber
_ —�/-✓��.2 —Go% � S�-!� 7
Is ihe prope(fy used arM ompied br Assassetl value ol the poperty as ol March 7, wrteM year (may rwt ¢xceetl f782,<30
hislner resiEencs7 lorO�er 65 dedudini, v 5760.000 /or No Ovrr 65 Cimut &ealrer Credi�
❑ Yes ❑ No
Was the appfram 65 years ot age or rrore on December 31 of the year
Have you filaC tor am/ ofher deductions7 H Ws, what deduUioea7 �'
❑ Yes � No
Hava yw fded (or deductians in any other muntyt If Yas, what cw(rty7
❑Yes ❑No
1lWe cerliry under penalty of perjury that the above and foregoing information is W e and correct and that the applicant was a residen[
of Indiana and owner of the aforementioned property on March 1, 20 _
Signalura o(appGfaM Pddress of appGmm (mmbereM stroel, firy, stafa, antl ZlPmde)
�� � �72 1. Iri� �/! V %670
Signature onzed raprasentativa Address of aulhorized representa a(nwn0erarM sfroel, dty, state, and LP co0e)