HomeMy WebLinkAboutAge_McBroomAPPLICATION FOR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
` '' Stafe Fwm 43708 (R9 / 9-08)
� PrexnbeE by Me Depanment ot Local GovemmeM Finance
Infortnation coniainetl in Nis tlowmenl is CONFIDENTIAL pursuant to IC 61.1-12-9 and IC 61.1-35-9.
TOWNSHIP
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INSTRUCTIONS:
To be filed in persw+ o� by mail with the CountyAUtlitw ol the wun y where fhe property is locafed. (� r�� y� o oa
Ffling Oates: 1) Real P/operty: Dunrn� the tweNe (72) monfhs 6e/ae December 31 0( the year Ne Geduction isY �D e ctrve.
2) Mobile Hames essessed urrder IC 61.7-7 or menulactured homes rrot assessed as real property: Dunrg the tweAre (72) months
before Mart� 37 olthe year Ihe deductlon is to be eRective. �i�„ ,Q�
See reverse side lor adddionel insLUCfions aM qualificafions. _,_ __ _ �_
Type of benefS (epue5ad (please tl+eclr ae Nat app�
� Over 65 Deduction from Assessed Valuation
Nameofapd�nl(o�nTrera'�� Q1.���l�'v'�"�-
�
U eooi�m ihe sota iegai or eQu�taaa ownen rc No, Mma� �a numar a.a
�les ❑ No
M reme an record'u dlfereM Ihan Ihet d appi'�nt, irMicate bebw
Name ot contraa sa�lar (app'mant must neve Deon euyilq on conbatt a� Mas ono (7) yoa�
naa�ess a m�,aaa �oe� cmmww e�a srre�t �m: sam,
Key numDer / Lepal dexription
a�- os-3a-3
U �he D�DeM used and occuDieO pQFnarily br
his/ner resideno7
� Yes ❑ No
Waa the appGCam 65 years of age a mae on December 31 W the year
prior to Me ameM YeaR
❑ Yes ❑ No
Adjusted gross income of applicant, spouse, and any
Individuals sharing ownership (FOr Over 65 deduction, income
may not exceed 525, 000; (or the Ove� 65 Circuit Bieaker Credit,
income may rrot exceed $30.000 /or individuals, or 540,000 lor
married couples).
Nava you fded tor a�ry olhar
� Yes �No
Have M�+ filed M aeductions in any ott+er cwMy7 '
� Yes � No
� Over 65 Circuit Breaker Credit
w in�eresl? It muned with someone ot�ar than soousa,
indiote wi�� whom
Is tne pmpetly in
Real properry � MoDile home (IC 6-1-1-�
Record number Page m:mbar
�- .39
0.ssewed value of Iha pmperty as o( March 1. cunem year (may nof erceeC 5182,a30
hr O�e� 65 deduclian, a 3160.000 /ur Ne Ovor 65 C'ucurt &oaker Cretli�
INJe certify under penaly of perjury thal the above and foregoing information is tr�e and cortect and thal lhe applicant was a resident
of Indiana and owner of the aforementioned property on March t. 20 '
Signature d appfxartl Mdrese ot aoP��:t (numbaaiM sboo4 ul�: sWfe, aM e)
T�' �°'^-�*� `J �.1.'R-CA-� �710
�Signetura of authonzad reo�asenWWa Addrasa of eNhwired repraseniative (numDer antl ' t ciry, stato. anC LPCode)
� � � ,..