Age_Kidwell •x;A. APPLICATION FOR SENIOR CITIZEN II -1 fu NSHIP I YEAR
PROPERTY TAX BENEFITS
- State Form 43708(R9/9-08)
Asa S f Prescribed by the Department of Local Government Finance
DEC 10 201 File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS: .f///'����p�I�,
To be tiled in person or by mail with the County Auditor of the county where the property is located.
.��npCC fr�1/1t`,dI^rr""'II 1' p
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the ye a1 tlNUd06Cbbnlisfto be elfec11.0R
2) Mobile Homes assessed under IC 6-I.1-7 or manufactured homes not assessed as real pmperty:During the twelve(12)months
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) rat_
Over 65 Deduction from Assessed Valuation c*Dyer 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer) T
Is applicant re legal or er? If No,what 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 sheet,city,state,and ZIP code) Is the property in question:
❑ Real property ❑ Mobile home(IC 6-1-1-7)
Taxing distnd Key number/Legal description Record number Page number
O6-H-/8 3oI-Dta oga-0011
Is the property used and occupied primarily for Assessed value of the property as of March 1,current year(may not exceed 5182,430
histher residence? for Over 65 deduction,or 5160,000 for the Over 65 Circuit Breaker Credit)
Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
Have you filed for any other deductions? It Ws,what deductions?
Yes ❑ No /7 S
Have you filed for deductions in any other county? if Yes,what county?
❑ Yes V No
I/We 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 af.rementioned property on March 1,20
Signature of applicant Address of applicant (number and street city,state,and Z code)
Sidnat of authorized re. -ntathie Address of authorized representative (number and street,city:state,and ZIP .ire)
•
J