Age_Garrett� APPLICATION FOR SENIOR CITI2EN TOWNSHIP r�
r __n, ?; PROPERTY TAX BENEFITS
•S � ;� StateFwm43708(R9/9-08)
Presvibad by Ihe DepaNment of Loral Govamma(n Fnance
Informatirn mntained in ihis documenl is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC G1.1-35-9. �uN �� � I I
lNSTRUCTIONS: C � �� n�
To 6e lded in persm or by mail with fhe CounryAuditor ol fhe county where fhe property is located.
Filing Dafes: 7) Real Property.' Dunng the tweNe (12) morrtlts be(we Decem6er 31 ollhe yearthe deductioGk$6GN6�TY AUDITOfZ
2) Mo6ile Homes assessed urMer IC 6-1.1-7 or manWactmed hanes rrot assessetl as real pmperty: Dunry (he MsNe (12J montns
6elpe Marrh 31 0/ fhe year the detluctlon is lo be efleclive.
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See ieverse sitle (or addAional insWdions and qualifications
Typa of benef.t requasled (p'eam tlieck aD Ihaf apply)
�,Over 65 Deduclion from Assessed Valuation �ver 65 Circuit Breaker Credit
Name of eppfranl (ownw a cmbactWyeQ
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k appfimnt lhe sd al or equitaNe rnmeR N No, whai is his/her ezacl share or interest7 I( ownad vrith someone other Ihan spoum,
indicate wiN xhom
❑Y� allo
N name m remN is diftarent lhan Ihat of applrcant, indicate bebw
IJanre d ca,�2a saoar �aaallcant musl naw neen nuyu�v on rnnract al leasf oire (�l rearf
Pddress ot mntrad seller (num6rf aM sbaeG �', stale, ar�d LP mde) �s Ne pmpeity in Question:
� fteal pmperty � Mobile home (IC 61-1-�
Tazing Eis[Acf Key numbar / Legal Casrription Record number Page numbar
' b�l 7- l y0o -DOD. 6 54- a/
Is Ihe popeM and ampieE ' �ly br Aueaed value ol ihe qoperry as of March 7, wrteM year (may riW exmaa S7B2,430
hisTharrasitlen ? /or0�4r65detludion,mE1W.000hiNeOv�i65Ci/cuf&ealcer[:mdi�
�, Yes ❑ No
Wav tha appfrs:it 65 yaars o! age or more on December 31 of Ne year
r�e yw raae �or a�y omar aaa�s� u�, wnai aad��a
�-�5 ❑ Na y. s.
Have yau (ded fw deductions in any olhar cwnry? If Yes, whal counry7
� YCS � NO
INVe certify under penalty of perjury that the above and (oregoing infortnation is W e and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March i, 20
Signaturedapp6cant PddrassofappGmnt (numOrlaMSbool,city,s7ate,arMZlPoode) ����
� � 7� S S e v, �.
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Signature of a 'zed re0�sentative Address o(zulhorimd rapresentalrve (numbrlami sheaf, dty, slate, andLPwEe)