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APPLICATION FOR SENIOR CITIZEN
� PROPERTY TAX BENEFITS
�� '.•••-; • State Form 43708 (R9 / 9-08)
presuima ey tha oavanmam of Lora� 6o.emmem Finance
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Infortnatiom m�iaineE in this tlocumen[ is CONFIDENTIAL pursuanl to IC 6-1.1-12-9 and IC 61.1-35-9.
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DEC g 1 201Z
To be filed in person or by mail with lhe CountyAudita o/ the cotmty whera the properry is located. C�MMM���---,,,���y�g---
Ftiim,7 Dates: 7) Reel Property: Dufig the IweNe (12) months be/ore December 31 0/ the ysar the deducfion is to be effective. �y
2) Mo6ile Hanes assessed urMer IC 61.1-7 or manNacturetl hanes Irot assessed as real piopert�Duu�p Ihe Aveha �xe) �`tlis
belore Marrh 37 o7the yea�the deduclion is to be eflactive. '�yuN COUNTy qUD TOR
See reverse side !ol add"Aional insWciions a�M qualifiwfions.
Type d baneN raquasted (poaso W eck aB fhaf appiy)
❑ r 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Namedapp4nM(ouner cmfraclG�ye�J �
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`9 %i �
Is apP��M the sde lepal or equitade awneY! H No, what is his/her exad share w iritarest7 tt wmed with somema ocher than spouse,
intlimte with whom
❑ Yes ❑ No
I( nama on recad'q ditferent ihan Cut of applirant, iMiceta belrnv
Nartre d mMraG seliar (app�icanf must hava be� b�yirg m cmbacl et least/�"{/
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Address d mntrarl mAer (nun6or antl stree4 �'. sFate, and LP wtlo) Is the pmperty in puestion:
Real pmperty � Mobile home (IC 61-1-�
Key num6er / Lepal desrriplim Remrd number Page numbar
, D.! - VOO . o�d / -CXnC)
U Ne poperty �ssetl aM ¢apietl prima�y br Pssessed vaNe of ihe proDarry az of Mamh 1, wRant year (may rwf airced f182,430
his/ner residenwT fu/ O�er 65 Cetlurlian, or 5760,000l0� No Over 65 Circut BreaAsr Credin
❑ Yes ❑ No
VJas Ure appGran165 years o( aga or mora on Oecember 31 of the year
Hava you filed for erry olher deductions7 tl �4s, what deduccons?
� Yes � No
Hava you filed for deducGons in any other cwnry7 If Yes, what coumy?
� Yes ❑ No
I/We certify under penaliy of perjury that lhe above and foregoing information is true and wnect and that the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20 _
siqna�urema�rxam aderessota�timm �numaerarasweLcrry,sram,ainziPmde)
`y', � o� �e ;ti� fe� ���70
Sign ure d a ' ed rapresentative Pdtlrass of auttwr�d reprewn e(number arM sheeL city. stefa. snd L mde)
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