HomeMy WebLinkAboutAge_MillerV
ti:.
APPLICATION FOR SENIOR CITIZEN
,... , PROPERTY TAX BENEFITS
` �; � Sble Fortn 43708 (R919-OB)
� Prascrihed by Me Dapartment of Local Govemment Finance
Information containetl in this doament is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
COUNTY � TOWNSHIP � YEAR j
File Mark
INS7RUCTIONS:
To 6e (led in persm or by mail with fhe CountyAutlitw o/ fhe counry where fhe property is located.
Filirry Dates: 1) Real Property: Dunng fhe fwelve (72) month5 6efore December 37 o7fhe year fhe deduction is to ba eNectrvve.
2) Mobile Hanes assessed urMer IC 64. 7-7 or manufactured 6wnes nof assessed as real pmperty: Dun lbe (12�rponftis
befare Merch 37 o/the year the tleduction is fo 6e eHective.
See reverse side 7a atlddional inshuctions and qualiflcations. "� � � n(�a
Type of benefit reQUested (ploeso Meck atl Net apply)
� Over 65 Deduction from Assessed Valuation
NameofapPficaM(owrierorcmtractDUyn� �
��i /1,t �i � � F X YJJI //L� o
Ls aDO��m tha sde legal or epuitaWe awneR
Yes ❑ No
If name on recaC is diRarent Ihan d+ai of a�dicanL ��diwta below
Name ot contracl seller (apdKanf m�sthaw Dcen Ouying m conVacl a!
Address of mntreG seller
� (� `
�Over 65 Cirwit Breaker CredlY�
snxre or�^,eres,T
orm (�) yca7
vmbw and sbool, cify, slate, aM ZIP totlo)
Key n mbaN legal
- �., �� /3 -.
Is Ihe pioparty used anC ottuped onmarJy tor�
hisiTer res'den�T
�Yes ❑ No
Was the aod�M 65 years of aBe or mora on Decamber 31 0l ihe year
O�ior to Na arraM yea(J
�Yes ❑ No
Adjusted gross income of applicanR gPouse, and any
individuals sharing ownership (ForOver 65 deduction, income
may nof exceed 525,000: for the Over 65 Circuit Breaker Credit,
income may rrof exceed 330,000 !or individuals, or 540, 000 for
mairied couples).
any mher deEUGrons7
� Yes ❑ No
Have you fJad fw tleEUCtions in any Wher cwnry7
� Yes ❑ No
I( oxneC
ir.Cimie
50��40.
o�ooeery in Quesnon:
�Real propery � Mobile home (IC 6-7J-�
� I Record numcer Page r.embe:
-�ao. :aG�-��
Assessed value of ihe om�erty as of Ma¢h 1, currem year (may not erceed a:62,a30
:or O�er 65 dotluGion, or 5160.000 7or tha Over 65 Circuit Broaker Credi�
� ��
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
X Sgnature ot apWiwnt MEress of a00��mrt (num0erantl sheN, ci.y. sta(o. and ZIP Codo
� � /�� � �1 `^�
\ i�c°% d rl� � �j F- ��O � e b b o �
�$ignature of euMwiied r0presanlaMe ACdrass authorizaE reorasentative (r,umborand stmet, ciry, state, and ZIP cotlo)