Age_Flick"'" APPLICATION FOR SENIOR CITI2EN
_- PROPERTYTAXBENEFITS
•S � ;• StateFOrtn43708(R9/9-OB)
Prasai6ed by iha DepaAment of Loral GovemmeM Finance
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Informatiom m�fained in ihis document is CONFIDENTIAL pursuanl tn IC 6-1.1-12-9 and IC 61.1-359.
lNSTRUCTIONS: `�
Tobefiledinpersonorbymailwith(heCauntyAUtl'rtorolfhemuntywherelhepropertyislocated. r�BS�'NCOUNTYi�U�ITOR
Filing Dates: 1J Real Property: Dunng Ihe IweNe (12J mmfhs be/ae Decem6e� 37 0/ the year the �etluction u fo 6e eflective.
2) Mobi/e Hanes assessed uMer IC 67. 7-7 or manWacturetl homes rrof assessed as reel prtrperty: Dunig Ute hreNe (12J monfhs
be/ae Mardr 31 of the year tNe tleduction is to 6e elfective.
See reverse side lor edddional insWdions arM qualifications.
Type d 6eneH reQuested (ploem rhock ell fhaf appl�
Over 65 Deduction 6om Assessed Valuation ver 65 Circuit Breaker Credif
Name af eppGrartl (awnar n confract 6uyerJ
Ls app&aM lhe sda lepal or equitaWe armeY7 If No, is h er ezad share w interesl7 N wmed wilh mmeone othar Ihan spouse,
iMitate vrith whom
❑ Yes ❑ No
tl name m �emN is diflareM than lhat W apqicant ����e babw
Nama d mntact seDer (appficanl musf have been buy'up m canfracl al lea5 one (i) yeaQ
Address M mntraU mAar (nvn0or eM streeL �y. stab. end LP co0e) Is Ihe piope�ty in Quesibn:
eal property ❑ Mobile home (IC 6-iJ-�
Tar.i`g d'¢ '/ Key number/ Lagal dasaiplion Recad numbar Paga number
- 7'ZG�f-o0 . -O
k the woPertY used and ampiad v�mariy br r���a �wa or me wocem � o� �,. ��, r� h�r,�w ��e s,az.a�o
hNhar �astlanra7 Ior Uer 65 doCUdim. o� 5160.000 tor Ne Over 65 Cbcuif &ea/ml Credit)
� Yes ❑ No
Was ihe appGrant 65 years of ege or mwe on December 31 of Ure year
r�a yw raad ra a�r ana, aad�n n�,. �� eea�uo�z
� Yes � No
Have you t�ad tor tledumons in any dher cwriy! If Ws. whal couMy7
s ❑ No
I/We certify under penalty of peryury lhat ihe above and foregoing infortnation is true and wrtect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20 _ ,
Signature d appfwanl Address of appGeM (numDer arM sboeL dty. sbfe, and ZIP mde) ��- �
�' ��' `7 .� � �v
SignalOre aulhorfzed represantativa Pdd(ass of author¢ed reprasenqtiva (nfen6or aritl dly, sfat¢, and LP cotle)