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Age_Sartore 4.•47."a APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP l YEAR ' Z''' PROPERTY TAX BENEFITS ".:. -.' State Form 43708(R919-08) 5, .;?P• ai. Prescribed by the Department of Local Government Finance F — a�, !Clr Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. INSTRUCTIONS: MAY 9 2013 To be filed in person or by mail with the County Auditor of the county where the property is located. Filing Dates: 1) Real Property.During the twelve(12)months before December 31 of the year the deduction i• be eff:q•Ve. , f. ma �/ 2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as t�p 4• *��r = (12)months before March 31 of the year the deduction is to be effective. �'f��UN COUNTY AUDITOR See reverse side for additional instructions and qualifications. Type of beneft reques�tedd((please check all that apply) I�S1 Over 65 Deduction from Assessed Valuation ❑ Over 65 Circuit Breaker Credit Name of applicant(owner or contract bayed � /� �/� � (/l]lv`(w�/) O� 61 air •'vi L` Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? If owned with someone other than spouse, indicate with whom Yes ❑ No If name on record is different than that of applicant,indicate below Name of contract seller(applicant must have been buying on contract at least one(1)year) Address of contract seller(number and street,city,state,and ZIP code) Is the property in question: ❑ Real property ❑ Mobile home(IC 6-1-1-7) Taxing dis . Key number/Legal description Record number Page number ^,-'!}l`/n � ,Z a--o S-..3y-0317-o00. 7SW o/S? Is the property used and occupied primarily for Assessed value of the property as of March 1,current year(may not exceed$t62,430 his/her residence? for Over65 deduction,or 5160,0W for the Over 65 Circuit Breaker Credit) ❑ Yes ❑ No Was the applicant 65 years of age or more on December 31 of the year Applicant's date of birth(month,day,year) If filed by a surviving,unmarried spouse, prior to the clrent yeaR what was the spouse's age at the time ❑ Yes ❑ No of death? Adjusted gross income of applicant, spouse, and any ,_,,,,„.. income may not exceed$30,000 for individuals,or$40,000 for $ married couples). TOTAL $ 0.00 Have you fled for any other deductions? If Yes,what deductions? ' Yes NO Have you filed for deductions in any other county? � If\bs,what county? El IYes L7No If Ve certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident of Indiana and owner of the aforementioned property on March 1,20 • Signatu applicant `� Address of applicant (number and street,city,state,and ZIP code) ��,K P 5 A! /oo 6 W� 3,...,/,‘,66 Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code) •