Age_Smith Ibe t APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
; , PROPERTY TAX BENEFITS
State Form 43708(R10/12-08)
\nin c Prescribed by the Department of Local Government Finance
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS: ILE
To be filed in person or by mail with the County Auditor of the county where the property is locate
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the year the d��e��du[��ction t P ffective.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed ai7Pappkp'rty: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(plea check all that apply) ON COUNTY AUDITOR
GIBS
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
sienAatieNa
Name of applicant(owner or contract buyer) '
Is applicant the sole legal or equitable owne �� If No,what is his/her exact share or interest? If owned with someone other than spouse,
indicate with whom
❑ es n 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 i uestion:
Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district I Key number/Legal description Record number Page number
a.0—1 IS -34 - 1103o00.1:13C
Is the 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 5160,000 for the Over 65 Circuit Breaker Credit)
IA Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
l
El Yes El 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 applicant Address of applicant (number and street,city,state,and ZIP code)
u1s S it%
Signature of authorized representative Address of authorized representative (num r and street,city state,and ZIP code)