Age_Villines "o APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR I
° ` PROPERTY TAX BENEFITS
e_r
6', /' State Form 43708(R10 t 12-08) ��
'%.�i-' Prescribed by the Department of Local Government Finance
f ;He Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-3y1
INSTRUCTIONS: 1Hi
To be filed in person or by mail with the CountyAuditor of the county where the property is located. JUN 16-ZO\5
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real perty: a twelve(12)months
before March 31 of the year the deduction is to be effective. TY AUDITOR
See reverse side for additional instructions and qualifications. G(BSON COUN
Type of benefit requested(please ck all that apply)
ver 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of app nt(owner or contract buyer)
Is applica e sole legal sole legal or er? If No.what is his/her exact share or interest? If owned with someone other than spouse,
indicate with whom
es ❑ 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 east one(1)year)
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
❑ Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
a( — la- e30I- 003.oao a'
Is the property used and occupied primarily for Assessed value of the property as of March 1,current year(may not exceed 5162,430
his/her 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? If Yes,what deductions?
❑ Yes ❑ No
Have you filed for deductions in any other county? If Yes,what county?
❑ Yes ❑ 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 of appli nt Address of applicant (number and. city,slate.and ZIP code)
Si at a of authorized representative Address of authorized represen .4zum.f r d street,city,state,and ZIP code)