Age_Roberts (3) •
B"kc. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
et.'�`' ' i PROPERTY TAX BENEFITS
State Form 43708(R13/4-15) C
I. Prescribed by the Department of Local Government Finance J �� 1 A ���•
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 CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property:Form must be completed and signedby December 31 and filed or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes ,
before March 31 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
• Type of benefit reque-,ed(please check all that apply)
ri Over 65 Deduction from Assessed Valuation ❑ Over 65 Circuit Breaker Credit
N-i-of applicant(o net fop ;ontrac�buyer)'•MI\ N� C %11)('v
applicarft4b sole I 'or equitable own* if No,what is his/her 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 t n that of applicant,indicate below Do all joint tenants or tenants in common reside on the property?
IY Yes ❑ No
Name of contract seller, w y Has applicant owned or been bu g`,a property under recordgd
t. contract for at least one(1)year,efor claiming deduction?
❑ Yes ❑ No
•
Address of contract seller(number and street,city,state,and ZIP code) - Is the pr p in question:
NOV 272019
• Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district
)
See reverse for details.
Is the applicant 65 years of age or more on December 3 f the year Applicant's date of birth(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
❑ Yes
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
•
ES i Address of applicant (number and street,city,state,and ZIP code)
s 5 ' P n IZ� ).b v,ll .;-3.Yl
Sign re of authorized representative Address of authorized representative (number and street;city,state,and ZIP code) /