Age_LinigerAPPLICATION FOR SENIOR CITIZEN
;6... . „ PROPERTY TAX BENEFITS
SfaIB Form 43708 (R9 / 9-08)
•� -� � Presaibed by the Oapartmem of Local Go�emmeM Finance
Infwmatiwi mntained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 anC IC 61.135-9.
COUNTY TOWNSHIP YEAR
OCT 1 9 2012
INSTRUCTlONS:
Tobefiledinpersonor6ymailwifhtheCountyAudRorolthewuntywhe�efhepropertyislocated. C.�,�Y�,.,-�--
Filing Dafes: 7J Real PmpeRy: Dunrn� the tweNe (72) montfis be(ae Decem6er 31 07 fhe year the deduction is to 6e eRecliva��
2) Mo6ile Homes assessed under IC 51.1-7 or manWactured hwnes rrof assesser/ as real�;�ND�l�rg �F e fwelreYi�r2onfhs
be/ore Malch 37 ollhe yeer the tleduction is lo be eflective. 7 AUUI ft
See reverse side fa atldifional insWdions antl qualrfications.
Typa ol benef.t raquested (pleaso rheck a0 fhat appy)
� Over 65 Deduction 6om Assessed Valuation �Over 65 Circuit Breaker Credil
Name ot appfiranl (owrrer a+cmt2ct b�yeQ
%(���-�� � �o..
k appfi�anl the sde legal or aquitaWe ovma(/
❑ Yes ❑ No
H nama on recorE is diHerent than Nat of eppGpnt, iM
Nama of miriact seDer
M
orre (fl Yea7
ifrtaresl7 If owned vnih saneone other Ihan spousa,
iMirate wi�h wtrom
AAtlrasa d mntrad mVar (mxn6ei aM sbea4 �: 56fe. ariC LP code) Is Ne pmpe�ty in Questwn:
� Real property ❑ Mobile home QC 614-�
7y�' ��� Key number / Legal descnWion Ramd number Page number
r
6 -I z-a7-io� -ooa . �o
49 the pmpeM used aM occupied primariy for Aasessetl value ot lhe praperty as ot March 1, curtent year (may lrot exceed S1B2,430
hisRiar �eSiCenm7 1or O�er 65 Cetlucliwi, or 5160.000 hr Ne Over 65 Ciinul Breaker Cradi�
�Yes ❑ No
Wav tha appWartl 65 years o er 31 0( the year �
prbr lo tlie airtent yea
��Yes ❑ No �t/
c
Adjusted gross income of applieant, spouse, and any
individuals sharing ownership (For Over 65 deduction, income
may nof exceed 825, 000: for the Over 65 Circuit 82aker Credif,
income may rrot exceed 530,000 /or individuals, or 540.000 for
married couples).
Hava you (JeC For arry olher deducGrns7
liave yw rum ror aeductions in ar�y aner
� Y�es ❑ No
z
❑ Yes � No
If}§s.whatdeductiorts?
S rnf
���.�� �� �
IlWe cerlify under penalty of perjury that lhe above and (oregoing infortnalion is true and correct and that ihe applicant was a resident
of Indiana and owner of the aforementioned property on March i, 20 _
,
Signalura ppwant � n Addressofa001iram (munDerarMstreeCtly.sbte.aMZlPCOde)
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Address of aWhorimd represenfative
sWet,aty,5ato,endLPcade) ,�7 ��� a