Age_Fritz (3) 7.4.sli APPLICATION FOR SENIOR CITIZEN . COUNTY TOWNSHIP YEAR
--" PROPERTY TAX BENEFITS ���111 $
„'. •g State Form 43708(R9/408) RJ II L D
S ui.-r Pr.+vibed by the Department of Local Government Finance pg' 1$1
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and C 5.97
UU 1166 2013
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county where the property is I d.
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 ofrt/��,I�I�r}�r �t,ITV A anise tto4, ,effective.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured hoMJPYlAsi b .Vic 1y.'Ddring 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 deck al that apply)
itit Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker_Credit
Name of 'cant( or contract buye "COI.}(,QQ.D Ma 1 ! 1S.Q1 • I -
�C? ¢e, 4 ld I` �b c�4 s .fir„kittonfle
Is applicant the sole legal or equitable owner? If No,what a-r exact share or inleredYr— tl oMled with someone other than spouse.
j�-�' indicate with whom
I XL.Yes ❑ No
I
If name on record is different than that of applicant,indicate below
Name of contra seller(applicant must have been buying on contract at least one(1)year)Q
Address ct seller(number and sbee(city,state,and ZIP code) Is the property in question:
?
Peal property ❑ Mobile home(IC 6-1-1-7)
Taxis: tnd Key number/Legal description Reccid number Page number
IIP A._. a 6- 1a-o7- aaF-00 3-f 7g-oat
Is the property used and occupied primarity for Assessed value of the property as of March 1,current year(may not exceed 5182,430
his/her residence? - ttt for Ov er 65 deduction,or$160,000 for the Over 65 Circuit Breaker Credit)
?t yes ❑ No I
Was the applicant 65 years of age or more on eceemmb`er 31 of the year Applicant's date of birth(month,day year) If filed by a surviving,unmarried spouse,
prior to the current year?
Have you filed for any other deductions? If Yes, hat deductions? I
Il Yes ❑ No
Have you filed for deductions in any other county? If Yes,what county?
❑ Yes 11,6o
IMe 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 I
Signature of applicant Address of appfoant (number and street.city,state,and ZIP code)
)°R- - 1 • . (p_73 , E. 6RD4Dw4t{ s—
Signature of authorized represen ' e Address of authorized representative (number and street.city,state,and ZIP code)