HomeMy WebLinkAboutAge_Dyson� "' a APPLICATION FOR SENIOR CITIZEN
� PROPERTY TAX BENEFITS
` '' Sdte Fpm 43708 (R919-OB)
P(ewibe0 by Ihe Departrnerit of Local Govemmertl FinHrce
Infortnation wntained in Ihis Cocument is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
INSTRUCTIONS:
COUNN TOWNSHIP � YEAR j
File Mark
au� 1 s 2o�u
To be filed !n persrn or by mail wifh the CountyAUtlitw of the county where the property is located. ,y��.
Filirg Dafes: f) Real Pivperty: Dunrn,7lhe fweNe (72) months be/ae Deaember 37 o/the year tlte deduction is t��� � �{y
2) Mobi/e Hanes assessed urrdei IC 61.1-7 or manulactured homes rrof assessed as real property: Dun�o�1ha1}a�ii��/�monfhs
6e/we Merch 37 o/the year the deduction is to 6e eHecfive. G�BSON Cw��'
See �everse side !or adddional insWcfions end quelificafions.
Type d baneft requasted (plaese dixk e9 Nat appf�
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of apd��1(a�+�er a cakract Duye
b BDO�iGTM ihe sda lepal O� BQUi�3WB OwneR It No, wha� i9 �i5�lter exad shara or Inte sl? If owned with someone dher lhan spouse.
inditate with whom
C� ❑ No
H name an racard is diReram Nan lhat d appfi�nt, indicata bebw
Name d cantracl seilar (a ' nt must Aave baon Guying m canLact at least orre (1J yeaQ
� Pddresa of contrad seDer u bwa�M sLaef, cdy, state, and ZIP cotle) �s iha pmoeM �n uuestion:
� Real pmperry ❑ Mobile home QC 6-1-1-�
Taxing Ei Key number / Legal Cescription Reco�d number Page rum0er
"o,�,�O=��•-�5= �' - - - -�a.7-0��--,
Is Ihe p perty used and oaupied pnmariy fo Assesse0 value ot lhe o�oerty as ot Ma¢h 1, currant year (may imf axcead St82.430
hislner residence7 1or Orar 65 dotlurlion. ar 5160.000 br Ne Wer 65 Ciia�it &eake� Credi�
es Q No
Waa the flpo6cam 65 yeara ot age or mwa on Decamber 31 of the year
Mave you filed for any other tletlucGms? II l§a, what deductions? /�
es � No ���/ `�""'"��
Hava you filed for deducimru in any dher courity7 �� 1§s. what cour.ry7
o �S r�
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
� Sgnature of aopficam Addeass of aoPtimr.i (numbe� anC sfroet, ciry. sfale. a�d ZIP code)
� � p ?° � y a 6�' ��-� ►�l P.�.�
Signeture ot auNOnzed represeritative AdEress of aulMrized re0rase��aiive (nmriboranE sfrtrot, ciry. sfaPo, antl ZIP cotle)