Age_Wernke - it APPLICATION FOR SENIOR CITIZEN COUNTY I TOWNSHIP I YEAR I
PROPERTY TAX BENEFITS l v�
State Form 43708(R10/12-08) I j_y p w
Prescribed by the Department of Local Government Finance � �HI
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. 2 9 2016
INSTRUCTIONS: FEB rCD 9 u
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 is terse tyV
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property:During the twelve' ((12N)nonrnsOR
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)
[2, Over 65 Deduction from Assessed Valuation [Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
LAD
Is applicant the sole legal or equitablC owner? If No,what is his/her exact share or interest? If dwned t someone other than spouse.
indicate with whom
►id Yes 111 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:
VReal property ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
L. 1a a1-(o0- 60;st-R 1-6,4-7
Is the property used and occupied primarily for Assessed value of the properly 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)
0Yes LI 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?
14 Yes ❑ No
Have you filed for deductions in any other county? If Yes,what county?
Yes LTJ No
IfWe 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 I1tAddress of applicant (number and street,city,state,and ZIP code)
eta �4 dd
� e ) 7 / S c A Fi /Ave.r rein, t' )/767
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)