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ej='"v APPLICATION FOR SENIOR CITIZEN
' PROPERTY TAX BENEFITS
�! z
3;� r' State Fortn 43708 (R70 / 12-08)
° Prescribed 6y the Department of Local Govemment Finance
Infortnation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
COUNTY � TOWNSHIP � YEAR
INSTRUCTIONS: O�� ` �
To be filed in person or by mail with fhe CountyAuditor ot the county whe2 the property is /ocated.
Filing Dates: 1) Real Property: Dunng the hvelve (72J months 6e/ore December 37 0( the year the deduction is toLn����
2) Mobile Homes assessed under IC 6-7J-7 or manufactured homes not assessed as �eal pr�fBe H r�
be(ore March 37 0/ the year [he deducfion is to be eBeclive.
See reverse side tor additional instructions and qualifwtions.
Type of beneft requested (please check all that applY)
� Over 65 Deduction from Assessed Valuation � Over 65 Circuit Breaker Credit
Name of appliwnt (owner wcontracf buyer) \�
(/� /'1
Is appliwnt ihe wle legal or equitable owner? II No, what is hisfner exact share or interest? If owned wiN someone
indiwte wilh whom
❑ Yes ❑ No
If name on recwd is diRerent than that oF applicant, indiwte below
Name of coniract seller (app/icant must have been buying on con(racf at least one (7J year)
5p0use,
AEdress of conVact uller (num6er and sfreat. tity, state, and ZIP code) Is lhe property in questlon: I
❑ Real property ❑ Mobile home (IC 6-1-7-n
i
Taxing distnct r Key number / Legal desuiption Record number I Page number
� -/l-i� - 3oa_oa� Sy�-o�-8
Is the property used and occupied primarily br Assessed value of the pmperty as ot March 1. current year (may nof exceed 5782,430
hisRier residence? �y forOver 65 deducfion, or 5760,000 tor the Over 65 Grcuif B�xake�Credd)
!S Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
prior to the year tazes are first due and payable?
� Yes ❑ No
Adjusted gross income of applicant, spouse, and any
individuals sharing ownership (ForOve� 65 deduction, income
may not exceed 525,000; for the Over 65 Circuit Breaker C�edit,
income may not exceed 530,000 fo� individuals, or 540,000 for
mamed couples).
Have you filed for any ocher dedudions?
Yes
Have you fled for deduclions in any other county?
❑ Yes
Applicanfs date f bir�h (i9rynth, d��J
/!-l�3`� `'r
�o -�-3 9 /3�-
Source of Income
i II L � �
�_•�
If Yes, what deductions7
❑ No !� S
If Yes, what wunty?
No
If filed by a surv'rving, unmarriea spouse,
what was the spouse's age at the 6me
of death? I
� Amount of Income
IS I
�5 �
TOTAL I5
I/We certify under penalry of perjury that the above and foregoing information is true and correct and that the
of Indiana and owner of the aforemeniioned property on March 1, 20 _
of appliwnt
ofauNOrized
� ��
was a resident
Address ot aOP���nt (number and streef, uty, state, an0 ZIP code)
%�D S . /tE'NSiivC�76 /L ��• P2i�sTon�� I !J .
Address of auNorized representative (numberand slreef, dry, state, antl ZIP code)