Age_Schultheis (2) x°a APPLICATION FOR SENIOR CITIZEN CO YEAR
PROPERTY TAX BENEFITS FIE
a f State Form 43706(R919-08)
w• Prescribed by the Department of Loral Government Finance
APR A
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. APR �I�'-'C111Y
INSTRUCTIONS:
litmegger-
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 B IgAQU NTY AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property: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 deck at that apply)
KIOver 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or cents-/buyer) /n/w
Is apprpant the sole equitable own what is histher 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 sever(number and sheet city,state,and ZIP cede) Is the property in question:
❑ Real property ❑ Mobile home(IC 6-1-1-7)
Taxis 'saki Key number(Legal description Record number Page number
Ate -a3-/7 - ,2ob - 000. f7o-b
Is a property used and occupied primarily for Assessed value of the property as of March 1,current year(may not exceed$182,430
his/her residence? for Over 65 deduction,or$160,000 for the Over 65 Circuit Breaker Credit)
Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
❑ Yes /NNO
IhUe 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 apprrant (number and sheet city,slate,and ZIP code)
Signature of authorized representative Address of authorized representative (number and sheet,city,state,and ZIP code)
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