HomeMy WebLinkAboutAge_Davis (7)� � "' APPLICATION FOR SENIOR CITIZEN
; = d PROPERTY TAX BENEFITS
S - '! Sbte Fam d3I08 (R919-OB)
Prescnbed by tl�e Dapartmerit of Local Govemmem Firance
Infortnation oontained in Nis tloament is CONFIDENTIAL pursuanl to IC 6-1.1-12-9 and IC 61.7-359.
couNn
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INS7RUCTIONS: ��� �
To be filed in person or by mail witb fhe CourrtyAudita o/ Ne county where fhe property is locatetl. Y
Filing Dafes: 1) Real Propedy.' Dunng fhe tweNe (12) months 6e(ore December 37 0( the ysar the deduc6on is to be eRec� 2 4 z U w
2) Mo6ile Homes assessed urMer IC &7.7-7 ormanufecture0 homes rrot assessed as real p/operty: Dunng the Me/ve (12) mondis
be/ore March 37 0/ Ne year fhe tletluctlon is to 6e eHecfive. �� ��
See raverse side lor edddional insLUCtions eiM qualificaUOns.
O
Tyoe of baneEt repuesled (please k a0 Nat appl� '
Ooer 65 Deduction from Assessed Valuation ❑ Over 65 Circuit Breaker Credit
Nameofa0�'�m(�TKKa��cfDUyer� � ^
� � �
Is a001itant the w!e lepal or aquitaWe owneR It No, what is hislner ezact ahare or inte�ast9
❑ Yes ❑ No
if name on record ia diflerenl Ihan that of aDd��t ��diwte bebw
Name
Pdtlrass
mart
���� �
Is ihe p(weM sed and xwped pnmanly lor
hisTherresidan�a7
cm✓act at least olre (111'�0
ciy, stato. aM zIP code)
� sameone Whe� I�dn spouse.
whom
a v�oerty in ouestan:
� Real property � Mobile home (IC 64-7-7)
Key number / Legal dascnption Record num6ar Paga number
��O-la-o�400-�Yof-�3 a7
Asseued value ot lha property as of March 1, wrt�
Por Orer 65 deduaion, a f i60.0001or fhe Ovel65
es ❑ No
Was the applicam 65 yaen ot age or more on Dacember 31 of tne year
pnor to Ne wrrem yea(7
es ❑ No
Adjusted gross income of appliwnR spouse, and any
individuals aharing ownership (ForOver 65 deduction, income
may not exceed 525,000; for the Over 65 Circuit Breaker Credit,
income may rmt exceed S30,OOOlorindividuals, orS40,000 (or
married couples).
Have you fileC tor arry Wher
Mave you (Jed fw Ceduc6ons
� YeS
counry7
� Y05
� •
�
APO���
Source ot Inwme
Ir Yes, v.1+ac ded�ctions?
I/ ffis, what county?
If filed by a suniving, unmameC spousa,
what was the spouse'S age af lhe time
of deaih7
Artrount of Income
Sa�
IS
TOTAL I S • 0.00
IhVe certify under penalty of perjury that the above and foregoing information is true and cortecl and that the applicant was a residenl
of Indiana and owner o( the aforementioned property on March 1, 20
� Signa reotaOM�cam ^� Pddressofa00��mm (num0oiendstrce4�'•ry.slafa,aiMZlPcode)
( —,�,�j � / c� % � O.CISE,Qr% , � �J�-
Sionature ot aufhorizetl reorese tiva Address ot autMrized repeasenta�iva (nambwan0 sbvaf, ciry, stafo. antl ZIP code)