Age_Hickman �':—• APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
r."4.`. PROPERTY TAX BENEFITS
f:c
\— '_� State Form 43708(R73I415)
•�re,."' Prescribed by the Department of Local Govemment Finance
1
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS:To be tiled 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 reaalproperly 1DDuring the twelve(12)months
before March 31 of the year the deduction is to be eff .
`
See reverse side for additional instructions and qualifications �
• Type of benefit requested(please check a8 that apply)
2 Over 65 Deductidn from Assessed Valuation ❑ Over 65 Circuit Breaker Crete!I Y - D
Name of applicant(owner or contract buyer) 1�-1 IyI/�Y111Jd ��I
Is applicant V� n equitable ? 1 �f�wh�n exact share or Interest? If owned with joint tenahf'N'tenant Cat
indicate with whom
IIK...e ❑ No rye If name on record is different than that of applicant,indicate below Do all joint tenants or r ib U NTY AUD TO R
E'Ses ❑ No
Name of contract seller Has appfant anted or been buying the property under recorded
N contract for at least one(1)year before claiming deduction?
Dyes ❑ No
Address of co seller(number and street city,state,and ZIP code) Is the property in question:
Real property ❑ Mobile home(IC 6-1-1-7)
Taring district Key number/Legal description Record number Page number
Vto ./rACOt-M ak.0-ao-ks.'Apo-col 2123-oo t
Does eppfttant reside on property? Assessed value of the proppeerty aso of wrtent year assessment date(may rot exceed
f Circuit for Over 65 Deduction w f/59,999(tormtin9 just Ne homestead site)fw 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 Applicants date of birth(month,day year) If filed by a sun/lying,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 LJ No
I/We certify under penalty of perjury that the above and foregoing information is true and correct. '.
Signature of applicant Address of applicant (number and street,dht state,and ZIP code)
X/6 d Vse-1. , X yo r17tM kJicy d ar.JJa .4 4—cr ,e9.-- sL4674
Signature of a representative Address of authorized representative (number and street oily,state,end ZIP code) -