HomeMy WebLinkAboutAge_Bennington� ' a APPLICATION FOR SENIOR CITIZEN
� PROPERTY TAX BENEFITS
�'• StamFwm43708(R9/408)
Prascnbed by the Deoartmer� o( Lacal GovemmarH Finance
Infortnatiom m�tainad in this Aocumenl is CONFIDENTIAL pursuant to �C 6-1 J-12-9 antl IC 61.135-9.
COUNN TOWNSHIP � YEAR
Fila Mark
DEC 3 - 2010
INS7RUCTIONS:
To be filetl In person or by mail wNh the CountyAudita o/ the county where fhe properry is located. � /I�
Filirrg Datas: 1) Real Property: Ounng fhe hveNe (72J months 6efore Decem6er 37 of the year the deduction is to e �(d/�vg`'
2) Mo6de Hames assessed urMer IC &7.7-7 o�manufactured hwnes rrot assessed as real p��(�u� t��sl� ���ths
be(ore Marrh 31 0! the year fhe detluction is to be eNecfive.
See reverse side for edddionel inshuctions and qualifications.
TYOe of he'reft re4uasted (W eck e0 Wt appy) .
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
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Name of appFrarit (mnrer a cdMiatl DuyeQ �..,
�
b epolimrit Ne sole lepal oraQUit eR If No, what is his,her exaU share or'unerest? H owned with mmeona Uhar than spa:sa,
inditlte with whom
Yes ❑ No
tt name on recoitl is diftere'n than Nat d appiican4 ��dicete below .
Name af mrtact se0er (appdcant must hare been buyirg an canfract at least olre (i) yeaQ
� Address af mntrad seller (numbor aM sbae4 �: sGfe, eM ZIP ca0e) Is the v�oerry in uuesibn:
� Real pmperty � Mobile home QC 64J-�
Tating distnd Key number / Legal descnption Record number Page rumeer
Cc�Q ��b.._ -3�=3_ - - = ==E�:o:i.—_t�-�e�
Is ihe p�opeM1y used and occupeE primany for Assessed value o( the DroDe�ty as of Ma`ch 1, wrterit year (may not ezceed 5182.<30
hialher res'dance? lor O�er 65 dNUUian, ar f760.O00 loi the Ovoi 65 Ciicuif &eekerCrerli�
Yes ❑ No
Was Ihe aod��M1 65 yean of ege w rtrore on Dacember 31 ot the year Apolimnfs date ot binh (mon+h, tlay, yea� It filed by e surviving, un:nartied soouse,
orror io ma o,rrem ywn what was lhe spousa's age af the time
❑,�5 o Na — �
Have you fJed for ary olher deEUCtiona7 I(1tes, what dedvctions?
❑ Yes ❑ No
Have you filad tor deductions in eny other cwrrty? �( �es, wha� counry?
� Yes ❑ No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a residenl
�of Indiana and owner of the aforementioned property on March 1, 20 _
Sgnetura a( a" m Address ot aDD�imrt (numberaM stroot, ciry. sfafe, aiN ZIP code)
e � ss
Sig o(auCiorized represenia' Atldress ot autMnzed raoresantative (numberan0 swet, ciry, sta.o, antl ZlPcatle)
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