Age_Heerdink '-4. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP I YEAR '
PROPERTY TAX BENEFITS b/ State Form 43708(R9/9-08)Prescribed by the Department of Local Government Finance
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. JUL 1 O p 2013
INSTRUCTIONS:
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,ic ���1yN�.t ��f/11
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real prope :�!"inng fgWigiW pW-6 ieR
before March 31 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Type of benefit requested(please check all that apply) -
aliver 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
4x4
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 suer(number and street,city,state,and ZIP code) Is the property in question:
Real property ❑ Mobile home(IC 6-1-1-7)
Tazin strict Key number/Legal description Record number Page number'
a�-�a�9_ /0O- . 1 f oar
Is the property used and occupied priman for Assessed value of the property as of March 1,current year(may not exceed$182,430
hisher residence? ...N����yyyT111 for Over 65 deduction,or S160,000 for the Over 65 Circuit Breaker Credit)
A Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
Have you filed for any other deductions? If Yes,what deductions?
C Yes ❑ No 1-i 5
Have you Ned for deductions in any other coumlT/+ It Yes,what county?
111 Yes 14 No
IfWe 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
( Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
? Ir„te2/ Z 0e t'( & Li 7o 5r3oari W. PA/At-/= w, /N 't7& 70
Signature of authorized representative Address of authorized representative (number and street,city,state,arid ZIP code)