Age_Willis (2) //..• "o APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
'k PROPERTY TAX BENEFITS /�yv
\ ✓' State Forth 43708(R10/12-08) 1 J LE
fie Prescribed by the Department of Local Government Finance \ ILJ
�p.J- ile Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS: APR 1 2015
To be filed in person or by mail with the CountyAuditor 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 de•t .% �Ir• • -f 1•1Y-4 ctive.
I
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assestaydg , - %1EitnAle(gpt e(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)
❑ Over 65 Deduction from Assessed Valuation T Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
��2,.
o e /1/4/). 420,A 2e
Is applicant the sole legal or equitable owner? If No,what is his/her exa are 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:
71Real property ❑ Mobile home(IC 6-1-1-7)
Taxin drict
0792a Key number/Legal description Record number Page number
2-4 -20-0R-90 l coo ,290? ciao
Is the property used and occupied primarily for Assessed value of the property as of March 1,current year(may not exceed$182,430
higher residence? for Over 65 deduction,or$160,000 for the Over 65 Circuit Breaker Credit)
I -+ Yes El No
Was the applicant 65 years of age or more on December 31 of the year
❑ Yes I-)4 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 aforementioned property on March 1, 20 .
Signature applicant Address of applicant (number and street,city,state,and ZIP code) // �J3�Ji^r-^ `c J
- ignature of authorized representative Address of authorized representative (number and street city,state.and ZIP code)