Age_Oprisko a - APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
A_— PROPERTY TAX BENEFITS
r
` Ir S Form 43708(R13/4-15)
�foi./ Prescribed by the Department of Local Government Finance
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-a
INSTRUCTIONS: 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:Form must be completed and signed by December 31 and filed or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property: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(please check all that apply)
fler 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of a plicant(owner or contract buyer)
Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? F l w dam' of t 1 tenant in common,
❑ Yes ❑ No
If name on record is different than that of applicant,indicate below Do all ioirRR nt�o�r� n common reside on the property?
��YY�I Yes ❑ No
Name of contract seller Has appli n the property under recorded
j 9 P. ing
� � rT(.r) }'�F(aiming deduction?
❑ Yes ❑ No
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
026-Q5 3l-aco-Co\. 533-D9'7
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
$182,430 for Over 65 Deduction or 5159.999[counting just the homestead site]for the Over
❑ NO 65 Circuit Breaker Credit.)
❑ Yes See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
Have you filed for deductions in any other county? �If•Yess,,what county?
111 Yes 111 No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
a48 ��
Signa re authorized representative Address of authorized representative (number and street,city state, ZIP code)