Age_DonohayR: � a APPLICATION FOR SENIOR CITIZEN couNn TOWNSHIP � YEAR
ry. . PROPERTY TAX BENEFITS
� !• StareFortna3108(R9/9-0e) 1
� Preauibad by the Depanmar.t ot Lacal Govemmem Finance
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Infortnation containeE in t�is doament is CONFIDENTIAL pursuant to IC 6-1.1-72-9 and IC 6-1.135-9.
wsrRUCnoNS: pEC 3 0 200a
To 6e filed in persm or by mail witb fhe CountyAUditw of fhe oounty where Ne property is locafed.
Filirrg Dates: 7) Real Property: Dunng the tweNe (12J months before Decem6er 37 0l the year the deduction is to 6e efl ttNel.�
V �'�ih
2) Mo6i/e Homes essessed uMer IC 6-1. 7-7 or manulactured homes rrot assessed as real prop��il&fa fhe htpAa 1121 mrnths
belwe Marrh 37 07 the year fhe deduclion is to 6e effecWe. ^� G���;TY O.UD�T
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See reverse side (a etltlitional insWdions eiM qualifications. :��ps� ••
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Typa N beneft reCUesteE �Woase dieck a0 fhat appry)
Over 65 Deduction hom Assessed Valuation Over 65 Circuii Breakei Credit .
Named ka�l( acontract0�yo�
V �
Is aOGlimrit ihe m!a leqal or eQuitabia ownaR It No, what is hislner exact s a. or inlerest? if ownad witn someor,e other than soovse,
indifate with wnom
Yes ❑ No
If name w recoN is diflerent than Mat d aodicant, indiwte below
Name of coniad SeAer (applicant muit �ave Scon Duyirg m conVact a! Icasf oiro (t) yea�
P.ddress of mntratl eallar (number aM street, crty, sfafo, arW ZIP m0o) Is ine �moeery in cuestion:
Real pmpery � Mobile �ome (IC 64-f-�
' Taeing Eistnet Key number! Legal tlasenotion //n Reeord num6er Page numoer
� O�p-/o�-09oT�0-�• 7�6'��%
Is IhB pmperty used and occu0�etl pnmarily br assassed value Of thB Drooehy as of Ma¢h i, Cur.ert year (may n0[ erxed 5182,430
hisfner rasidenw? !ar O�er 65 doduclion, w 5:60.000 lor I�e Ovor 65 Ciicuit Broaker Credip
� Yes ❑ No
VJas ihe apd�� fi5 years of age w more or Decembar 31 of Ihe year
Have you filed for eny Mhar daducUOns? I If Vas, whal aeductions7
� Yes ❑ No
Have you filed tw Ceductions in any other munry7 If Yes, wnat county?
� Yes ❑ No
I/We cartify under penalty of perjury lhat Ihe above and fore9oing information is true and correct and that the applicanl was a resident
of Indiana and owner of lhe atorementioned property on March 1, 20
' nal U axlram PdLress of aoo��r,t (numGCrantl swet. ciry, s:a:o, antl ZIP mde)
/ //. ` 9�'/w!/( ��°Z L �iW�-- � � %7 ^!O'
' Signature Naulhonzed representa5ve AEdress ot auttwrizeC reaaseniative (numbcr antl s;root, ciry, st .o, antl ZIP codo)