Age_MontgomeryI
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�"' a APPLICATION FOR SENIOR CITIZEN
r.,• 4 PROPERTY TAX BENEFITS
S ! State Fortn 63�08 (R9 / 9-08)
Prescnbad by �he Depari.�nenf of Local Go�emmeM Finaxe
Infwmatiom m�faineE in Mis tlowmenl is CONFIDENTIAL pursuant ro IC 6-1.1-12-9 antl IC 6-7.135-9.
COU! T NS YEAR j
oE�e�� zuiu
INSTRUCTIONS: � � � �
To be filedln person or by mail witA the CountyAUtlita o1 the wunty where fhe properry is /ocatetl.
Filing Dates: 1) Real P�operty: Dunrg the tweNe (72) months before Decem6ei 31 0/ the year the deduction is t��@liiiO.QUNTY AUDITOR
2) Mobile Hames assessed urrder IC 61.1-7 or manufactured hwnes rrot essessed es real property: Dunrg the hvehre (72) months
befwe March 37 0/ the year fhe deduc6on is fo 6e e/lective.
See reverse sitle for adtldional instnidions eM qualifications.
Type of banefit ra4uastetl ease rliock e01he( epply) � /
Over 65 Deduction from Assessed Valuation IA1 Over 65 Circuit Breaker Credit
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Name o( aoP��m (owr�er w CPn4acf DuyoQ
/ �
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19 dpOfiqfi� fhB SOIB IB921 Of BQUi�3dB OWI1B(7 If No, what is his/ner exaG shara w i'rt rest7 1( OW(1 �h SOTI e Wher t�an sDOUSe.
ifldl B 1hW:lOT
❑ Yes ❑ No
H namo on'acord is d.9afeM Nan Ihat d epWitsn� IMicete balow
Name of mitaa se0er (nppllcanf musf fiave beon Duying m canhaU af leasf arre (fJ yeaQ
Addreas of mntraC sa0er (numbora�tl sbeef, ciy, state, end ZIP ootle) �5 the D�Ce in Queslion:
Real pmperry � Mobile �ome QC 614-�
Tanirg di Key num6ar / legal description Racord number Page numDer
� � � � f �oc,6�-/
b ih M1y and occup prinurily for AssesseC value o( l�e WoDeM as of March 7, wRem year (may rrof ercce0 5192,a70
hi r iesWen 1 Por O�er 65 tletluUion. n 3160,000lor Ne Over 65 CircYdt Breekai Ciedif)
❑ Yes ❑ No
Wiv the aOC�M 65 yaars of epa or rtara on December 37 d tha year
AmouM of Income
Individuals sharing ownership (ForOver 65 deduction, income �
may not ezceed $25,000; for the Over 65 Circuit Breaker Credit,
income may not exceed 530,000 (or individuals, or 540,000 for I�
memed couples).
ITOTAL I $ 0.00
Have you filed tor arry olhar dad�ctions7 It Ves, wfiat deEuctions?
❑ Yes ❑ No
Have you fled tw daductbns in any other cw�rty9 If 1%s, wnat counry7
❑ Yes ❑ No
IIVJe certify under penalty ot perjury thal the above and foregoing information is true and wrrect and fhat the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20 _
.� nature of appfiram Mdress of apoli�M (numDOr arM srtool, cury, stafe, aM ZIP code)
; � "34 .
Signature of auU�onzed represeMative ` Address of aNhmizad raDresentative (numDOr arM stroot. ciry, sfafa, and LP code)