Age_Conner d "o APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
m. ` PROPERTY TAX BENEFITS ��
at ,
rre State Form 43708(R13/4-15)
•'ele` Prescribed by the Department of Local Government Finance
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. JUN 1 3 2018
INSTRUCTIONS:To be filed in person or by mail with the County Auditor of the county where the property is located. J .
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Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked byemf§l•,14.•{{1�i���Nt•d:• :'A.r
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property:Dunng t e hWEWC 1 7mAhEOR
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)
L✓ Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
Cr i\er �0L-ctc d
Is ap'Qflcant the sole legal or equable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,
indicate with whom
-1 es ❑ No
If name on record is different than that of applicant,indicate below Do all joint tenants or tenants in common reside on the property?
❑ Yes ❑ No
Name of contract seller Hasapplicant owned or been buying
contract for at least one t bf the property under irn?orded
( )year before claiming 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 03 S— 0 °
R rd number Page number
Pf7�f. rN_c-e au-va-\g - tot- od3.
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$159,999[counting just the homestead site)for the Over
e8 El No 65 Circuit Breaker Credit.)
See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year Applicant's date of birth(month,day year) If filed by a surviving,unmarried spouse,what
prior to the year taxes are first due and payable? was the spouse's age at the time of death?
Yes ❑ No ?- 30- CACQ
Adjusted gross income of applicant,applicant and spouse, or Source of Income
Have you filed for any other deductions? If Yes,what deductions?
Er.A'es ❑ No
Have you filed for deductions in any other county? ,—, If Yes,what county?
❑ Yes L�eNo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signal • of applicant Address of applicant (number and street,city,state,and ZIP code) .
Signature of authorized epresentativ Address of authorized representative (numb r and street,city,state,and ZI code) th-