Age_Antey ,^' �% APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
7.' "�, 1 PROPERTY TAX BENEFITS
:, F:■ IQ'S Q`� State Form 43708(R13/4-15) � �1 9
r-is Prescribed by the Department of Local Government Finance ��1- l
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 Assessed Valuation ❑ Over 65 Circuit Breaker Credit
Name of applicant(ownero ctbuy r)
1
Is applicant the s I al 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
❑ 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?
FILED es ❑ No
Name of contract seller Has applicant owned or been buyi th roperty under recorded
contract for at least one(1)year bet iming deduction?
OCT 16 2Q1g Yes ❑ No
Address of contract seller(number and street,city,state,and ZIP code) Is the prope in question:
Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district Keyorf alst3 gd • AUDITOR R ord number Page number
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
$182,430 for Over 65 Deduction or$159,999(counting just the homestead site]for the Over
❑ No 65 Circuit Breaker Credit.)
❑ Yes See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
❑ Yes KNo
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,city,state,and ZIP code)
oy. evy,tu4 20 \ S M„AsH- ow\ ,s--\- FoPtisv)--Y) -(IN41
ignature of uthorized representative Address of authorized representative (number and street,city,state,ind ZIP code)