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�APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
Slale Fpn a3]08 (R 10 / 12-08)
� Prescn'betl �y Vie Depaftment of loW GovemrtcN Fvwnce
Infortnation wntaineC in UJS docvmem is CONFl�ENTInL pursuant to IC F1.142-9 aM IC 6-1.1-359.
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INSTRUCTIONS:
b be fJetl in person wOy maA wi:h t�e Go�ntyAWitw ol lhe counfy where Ne propeRy is bcaleC �7 /-�
Fdvg Dafes: i) Real PrupeM� Dunig Me MreNe (12� mon:hs bePora Oecember 31 o/Me year Ne detlucfun is to be 9�e� �v
1) MoDde Hwnes assessetl uMer IC b-iJ-7 w manWacNreC hwnes rrof assesseJ as real pro ' Dunng t��Ne (12�Ihs
oerore�.!a�aaormeyee�meeeaoa:onrstooeenecGre. �'r�$ONCOUNTYqUD17pR
See reverse si0e lw aetltional insLVCtions and pua4RCafqns.
I irx a emee� rewez�ee /v'� cn«w e� Na� ecNrl ,,_,/ /
�'. Over 65 Deduc�ion hom Assessed Valuation �✓ Over 65 Circuit Breaker Credit
� nm d,wticam fon.re.w cmo-ea ouywy .
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. ��aae w�r u
Ves ❑ No
Narx of wnvad uler (applcaM muzt nave Oeen euyig on c�d at leau me
Is Ve :
:icner
sfreel, nry 9ale, aeMZIP[We)
Legal aesrnD�
[v]�Yes ❑ No
N`as Oro applir:an165 years W age a rmre on oecemEer 31 ot tln year
mnm� re+�a.�arer�aiaoaamwyad�x,�/
� (� yes ❑ No
Atljustetl gross income of applicant, spouse, and any
individuals sharing ownership (FOr Over 65 deductbn, income
may not ezceed 525,000: lor the Over 65 Circuit Breake� CreOit,
income may nof exteetl 530,000 /or individuals, or 340,000 /or
martied coup/es).
Ha�e r� r�ee iw any omer a�e�ea„:�
[y��s
ia aee�nonz in aRy w�e. wunty>
❑ Yes
❑ No
ii .
a hier��?
Ca:v
u ow�ea wun zen,con: o�c� u,zn :owse.
��,araie �m,kwm
ISN<prOppMN 540n'.
Real pmpetly ❑ Alopae �ome (IC 6-1-1-n
ftccortlnumeer PagenumMr
Source ot
� • U � � � U U �n
u M MarC� 1, curtera year (may iroi e_ee0 S IBi.qG
M1J MNe Ovr 65 CiiclN &eaiei GeEin
aay yvan u raeo oy a wr.i.v+q, urmameo spw
xTa� was IM1e s�use'S age al Ne Lm
oi e.ame
ame Amounl of Income
5
3
TOTAL S 0.�
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tlWe certify under penalty of perjury that ihe above and (oregoing informalion is irue and cortect antl tha� ihe applicant was a resident
of Indiana and owner of �he aforemenlioned property on March /, 20 �.
g�aNre W a0d��� MCrezs al aPOk �� (nu'nDei zna ibrel. ury stale. aM IIP cNe)
/t'1 � 3 � � �0� S ��c ��� Ct
�amr.aa�nw�zeae Aea�essaiauvw�zec.eaesendwe(��mee.e.msuee�, yv»ie.axzia�oee) ^
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