Age_Grubb djq APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
.— - PROPERTY TAX BENEFITS
ati State Form 43708(R13/4-15)
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. ILED
FINSTRUCTIONS:To be filed in person or by mail with the County Auditor of the county where the property is lo .
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked bye folbvrjpg1frglary 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property: unng t e twelve(12)months
before March 31 of the year the deduction is to be effective.See reverse side for additional instructions and qualifications. J
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Type of benefit requested(pleas eck all that apply) N�'�'^
Over 65 Deduction from Assessed Valuation ter 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
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Is applicant the sole legal sole legal or equitable owner? If If No,what is exact share or interest? If owned with joint tenant or tenant in common,
indicate with wham
❑ Yes ❑ 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 0 No
Name of contract seller Hasa applicant owned or been bu
ying vying the property under recorded
contract for at least one(1)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 Record number Page number
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Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
5182,430 for Over 65 Deduction or 5159,999(counting just the homestead site)for the Over
I NO 65 Circuit Breaker Credit.)
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❑ Yes 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
Adjusted gross income of applicant,applicant and spouse, or
❑ Yes ❑ No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Sig ature of apprcant Address of applicant (number and street,city.state,and ZIP code)
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ignatu uthorized represenative�� Address of authorized representative (number and street,city state,and ZIP code)