HomeMy WebLinkAboutAge_YamashitaAPPLICATION FOR SENIOR CITIZEN
r . .. : , PROPERTY TAX BENEFITS
` "' StaOe Form 43708 (R9/ 9-OB)
� P(esfii6ed by Me �epartmer�t of Local Govemmam Finance
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COUNTY TOWNSHIP I YEAR
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File
Infwmatbn containatl in this Eowment is CONFIDENTIAL pursuant lo IC 6-1.1-12-9 and IC G1.1-35-9.
MAY 1 0 2010
INSTRUC710NS:
To 6e filedln person or by mail witA fhe CourrtyAudRa ol the munty where fhe properry is located. �y,,
Filing Dafes: 7) Real Property: Dunrg fhe hveNe (12) months 6e/ae December 31 o/fhe year the deduction is to be eflective. p�( �Q�
T) Mobile Homes essessetl under IC 6-1.1-7 ormanu/acfured homes rrot assessed es reel pioperty: Dun�g thelnslve (l�onths
(31tl5C1N C UNTY AUDITOR
6etare Marcir 31 07 the year fhe detluction is to be eflective.
See ieverse side fa atltldanel inSLVGions a� qualiAca(ims.
Type ot beneAt �evuested (ple9se Mxk e9 �hat appy)
Over 65 Deduction from Assessed Valuation Over 65 Circui[ Breaker Credit
Name ot apvGcant (owner a cantract OvyaQ
•
(�i
Is eDO�itant the sole tepal or eQUitable awneR If No, what is hisRier exact share w inta�asl9 tt awned with someme o�her Ihan spoase,
indimta with whom
� Yes ❑ No
H name on record is diflareM tnan that ol applicant, indiwte bebw
Name of coniad seller (eppllcant mvst havc boon buying on cmvaa at leasf ono (1) yea�
Pddress of mntratl seller (numDw arM sbeot, cdy, stale, aM Z/P code) Is t_he D�/oeM in Queslion:
U( I Real pmperry � MoDile �ome (IC G7-7-�
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Taa'vig disinct Key numher / Lepal descnption Record number Page nu:ncer
c�nc�� � /3-as�iao• 66�i9�s�
U the proDeM usad aiM occuped primanly br Assessed valua of �he pfoparry as of Mam1i 7, wrreM year (may not exceed S� B2 d30
hia/ner rasidenm? forO�er 65 deductian, a 5166.000 !or Ne Ovor 65 C'ucvil Breakor Credi�
� Yes ❑ No
Was the applirant 65 yeen of age or more on Oecember 3� of the year
ot dwth?
� Yes ❑ No
Adjusted gross income of applican; spouse, and any Source oi income Amount of income
individuals sharing ownership (ForOver 65 deduction, income S
may not exceed $25,000; for the Over 65 Circuit Breaker Credit,
income may nof exceed $30.000 lor individuals, or 540,000 for S I
married couples).
TOTAL I S 0.00
Hava yov filad for a�ry other deducEms7 I�� �'es, w�hat deEuctions?
� Yes � No
Have you (ded for dedudions in any other cwr�ty? If Yas, what wunry?
� Yes ❑ No
I/VJe certify under penalty ot perjury that the above and (oregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20 _
SignaturaolaOD��m Pddressoteo0licar.t (numGwnnOStroeLCiry.staM aridZlPcodo)
�a�SSa8 � � �'�c�'�-� �a���
Signature o honzed representative` Mdress ot eut�orizad re�re%ntativa (numbera�M stmef, ciry. stafo, and ZIP coCe)