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tr+�. APPLICATION FOR SENIOR CITIZEN o ;?( acillz YEAR
li, PROPERTY TAX BENEFITS ! •
_ State Form 43708(R73/415) ^A
Prescribed by the Department of Local Government Finance qP a
y Wile Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. GIeSON rf++,,,, ..YY
biorINSTRUCTIONS:To be filed in person or by mail with We County Auditor of the county where the property is cat" l
Filing Dates: 1) Real Property Form must be completed and signed by December 31 and filed or postmarked by 7g January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property Duringb 0Aplve(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 requestedd(please check a➢ apply)that
XOver 65 Deduction from Assessed Valuationf Over 65 Circuit Breaker Credit
Name of a (owner or centred 41/
' Is applica the sole legal creeds owner/ If No,what is his/her exact share or Interest? If owned with pint tenant or tenant in common,
indicate with whom
❑ 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 Has applicant wined or been burying the property under recorded
confad fw at least one(1)year before daurvng 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)
Tatin bid Key number/Legal description Record number Page number
i1Iit II-J -of-Ja/- oaa. 77S-0a?
Does epp8cent reside on property? Assessed value of the property aso of anent year acsecsment date(may not exceed
65 Circuit 30 Breaker Credit)
❑ Yes See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
❑ Yes ❑ No
Have you fled for deductions in any other county? y?If Yes,what count
❑ �/Yes QCI No
l/We certify under penalty of perjury that the above and foregoing information is true and correct. '.
.[ Signs re of applicant �lAI�I_ 1 0 /Address of applicant (number/er end street city,�state,and ZIP code) +.�.
•
ICC.4172
✓�`esiQ t� S.G 1 G. a,...-..-�Ii.aJ' et 1.4-sw� ce..Ge'+ti 44ir(..}'a
Signature of auu 'zed representative Address of authorized representative (numberand sbeetylr.state.end ZIP code)