HomeMy WebLinkAboutAge_WallerAPPLICATION FOR SENIOR CITIZEN couNn � TOWNSHIP � YEAR i
' .s 1..= ,. PROPERTY TAX BENEFITS Tf � I
State Fortn 43708 (R9 / 9-Ofi) �%
� Prescnbed 6y Ne Departmen� of Local Govemmem Financa �
File Mark
Informatiom m��ainatl in lhis doaiment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.735-9. �E � 3 � Z��$
INSTRUCTIONS: '—y�,
To be filed in persm or by mail wifh the CountyAuditw of the county wbere the property is locafed. Q�(G�., �Q
Filiry Dates: 7) Reel Pioperty.' Dunrn� the tweNe (72J months 6e/ore Dewmber 31 o/tM1e ysar the deduction ��t,����eNeptnivej
2) Mo6ile Hwnes essessed under IC 6-1J-7 ormanulactured homes not assessed es rea/ p�operty: Du�g N"e4C�hYe �1�1,r�
be(ore March 3t o7 the year the deduch�on is to be effecWe.
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See reverse sitle /a additional insWGions a� qualifications.
Type of benePo rapuested (ycasa theck aA Nat apply) I
er 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credit
Nama of epplicarit (owrrer or cmtract b�ye�
� •
Is aoDlipm the sde lapal or eQuitable af.� If No, whal is his/her exact share or interest? If owned with someone other than soouse.
indipte vAth whom
� Yes ❑ No
It name on record is dlflerent ihan that of aod�canl indirate bebw
Name o( contraG sallar (appl'rant mus+haw been bvying a: can✓acf at /east orro (1j yca�
Pddresa of mntratl seller (num0er a� strcet. cdy. sfam, aM ZIP wde) I �s iha omoerty in auestion:
Real prope ,ry � Mobile home (IC 64-7-7)
' Ta+in6 d'amtt Key number / Legal descn�tia� I Record num5ar Page rumter
d�-l`�-� - b � b �- O
b Ne v�oeM used and occuoied onmany for Assessed value of the Dro�eny as ol Ma¢h ;, curtant year (may rat ercecE i;82,a30
hiaRier rasidence? :o� O�er 65 doduaim, w St60.0001or No Ovw 65 Circur, &caker Crtd��
Yes ❑ No
Was the eppGcarit 65 yean of age w mwa on Oacember 31 of lha year A�vli2nfs tlate of oirth (mon;h, Cay, yaar) If filea by a suniving. ur..marreC sprn:se,
or�or �o ma a,rr�m yean w'hat was the spouse's age at the time
ofaaatn?
Yes ❑ No — �
Adjusted gross income of applitant, spouse, and any � Source of Income � Amouni of Income
indivlduals sharing ownership (ForOver 65 deduction, income I S
may not exceed 525,000; !or the Over 65 Circuit B2aker Credit,
income may not excaed 530,000 for individuals, or 540,000 fw I S
married couples).
ITOTAL I S 0.00
Have you filad for any othar deductior.s9 If Yes, what tleductior.s7
�Yes � No
Mave you (ied for Eeductions in any dher counry0 If Yes, what wunry?
� YES �
I/We ceAify 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 Maroh 1, 20
Signature d appGfant Address of aoolicant (numDerantl streef, ciry, staro. antl21P wtle)
�s S fe�i'�
' Sg atura o wized oresama e dress of autnwizec reoresentative (numDarand sbeet, ciry, staro, and ZIP co0o)