Age_Smith (8) " APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�'Sy, PROPERTY TAX BENEFITS
NSjz
State Form 43708(R13/4-15) ���� �" `'1I'
Prescribed by the Department of Local Government Finance 11141/
•
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
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)
Over 65 Deduction from Accessed Valuation
Ill Over 65 Circuit Breaker Credit
Name f appOceM( contract bu r) `
�ncAo` SM1 .
• Is applicant the sole legal or equitable owner? If No,what is Nslher exact share or interest? If owned with joint tenant or tenant in common,
indicate with whom
Yes El No
If name on record is differ t n that of appll ant,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 tuft th property under recorded
contract for at least one(1)year before claiming deduction?
❑ yes ❑ No
Address of contract seller(number and street dly,state,end ZIP code) _ Is the prope in question:
• Real property ❑ Mobile home(IC 6-1-1-7)
Tale district Key number/Legal descriptionR rd number Page number
Does ap reside on property? Assessed value of the property as of current year aeseesment date(may not exceed
Ded
uction for Over 65 or$159,999(counting just the homestead site)for the Over
65 Circuit Breaker crest)
❑ Yes El No
See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year Applicant's date of NMI(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
Have you fled for any other deductions? If s,t deductions?
��JJ 77
C� Yes ❑ No S�-eAct MAY 10 2019
Have you fled for deductions in any other coup �� If Yes,what county?
Lives El No 6 '
COUNTYJ� DITOR
liWe certify under penalty of perjury that the above and foregoing information is true aCd& t •
Signature of applicant Address of applicant (number end street,city,state,and ZIP code)
X da 44:41 kr os- N sfi tq �n ten - ��
Signature of authorized representative f`/1 c Address of authorized representative (number and street dry,state.and ZIP code)