Age_Grubb n"1 APPLICATIONPROPERTYTAX FORBENE SENIOFITSR CITIZEN COUNTY TOWNSHIP YEAR
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¢tit1 State Form 43708(R 13/4-15) r
me, ' Prescribed by the Department of Local Government Finance
_.... .fmr affirr
II- • -rk
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
DEC 2 0 2018
INSTRUCTIONS:To be riled 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 postmarkedbJlftg r anuary 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as r®(�NNNjy -the 1tfl f13nonths
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)
Over 65 Deduction from Assessed Valuation 0 Over 65 Circuit Breaker Credit
Name of applicant�/l (owner or contract
t buyer)
X /T'/^
Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,
indicate with whom
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 Has applicant owned or been buying 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:
it al property ❑ Mobile home(IC 6-1-1-7)
Taxing tact Key number/Legal description Record number Page number
r,-Cd921—) a6 - ia -/5 - /oa - ood. Feco -0). )
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
�/ S182,430 for Over 65 Deduction or S159,999(counting just the homestead site)for the Over
Yes ❑ No 65 Circuit Breaker Credit.)
See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
;—
Adjusted gross income of applicant, applicant and spouse,or
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.
Signature of applicant / Address of applicanty (number end street city,state, ZIP code)
tiPl •• i(1i� jeA '7 HI l 4- ) C �$2�`�"L „St/2-
Signature of authorized re resentative Address of authorized representative (number and street.city,state,and ZIP code)