Age_ColemanAPPLICATION FOR SENIOR CITIZEN co 7Y, - TOWNSHIP rena i
� - ^= 1 PROPERTY TAX BENEFITS � :;
` -_! SbmFwm43708(R9/448) ; S. .
� i Prascn6ed by Ihe Deoartmem of Local GovemmeM Finance i
� ��ileAAark L U �O
In`ormatiom m�tained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC &7.135-9. 9
INSTRUC710N5: �
To be fileC In person a by mail with fhe CountyAudifw o/ the �unty where the propeM is located. ' �/
•"�--��y
Filirq Dalas: 1) Real PropeRy: Dunng the MreNe (12J monfhs 6elore December 37 olfbe year fhe tleduction is tobe elfec,tivan�NTY AUDITQR
2) Mobile Homes essessed under IL 6-7. L7 ormanulacfuretl hcvnes rro( essessed as real pmperty.`Ounng the twelve (72) monfhs
belare Marrh 37 0/ fhe yeer the deduction is to be eRec6be.
See reverse side !a edddionel insWCfions end pualifications.
Type d benef,t reQUested (plaese chack a➢ Nal appl}�
er 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credif
Name O} eD0��C2�1( OI CMbBtt O(ryB/f '
b eooiimm the e lepel o� eQuitaWe e!J If No, what u hiSRier e:�act share or iMerest7 If owned with swneone oihe� than sDwsa.
indipie vAt� wtrom
❑ Yes ❑ No
If nnme on recard is diflareM Man Na� of aDp�icant iMicate bebw
Name ot conirsa saner (epp�cant must nare oeen Duy'up m cantraa at kas7 one (�) yea�
ldOreas ot contraa saper (numDOreM sbeef, cdy, atare, aiW ZIP oode) ; Is ihe v�oery in auastion:
� Real pmperty � Mobile homa QC 64J-n
� Tazinp Cist Key numher! Legal Oeacnption Recofd numDer Paga numbar
�����, - - a
U Ne p�opeM used end occuded primanty br A55eue0 value of the property as af emh 1, wrrent year (may not exceed 5782,d30
his/her residenm7 Ior O�er 65 detlucfion, w 4760,000 Ioi Ne Ovei 65 Ciicuif &eaker Credi�
❑ Yes ❑ No
Waq the appfrzM 65 years of ape or mo�e on Decamber 31 d ihe year .� Aoo��nib date ol birth (mwi7A, day. yoa� If filed by a wrviving, un,mamaC sDOUSa,
prior to Na arteM yea(7 - what was the spouse's age al the tima
� Yes � No - of death?
Adjusted gross income of appliwn; spouse, and any
Hava you filed fw a�ry othar Eeductbns7 I�t Ws, w�hat dedvctions?
� Yes � No
Mave you filad for tledudmna in any othar murrtyl I If 1§s, what counry?
� Yes ❑ No
IIVJe certify under penalty of perjury that the above and (oregoing information is true and correcl and thai the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 -
$ignetura W aopGCar� Addeasa of e00��r.t (namboientl sboof, ciry. state. a�M Z/P co0o)
� Sipnature a(auLhonzed �e0 eerrtative PGdress of aultanzec representative (numberarN� f. ciry st�nd LP c�o