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,:'"w= APPLICATION FOR SENIOR CITIZEN CO TOWNSHIP YEAFt
PROPERTY TAX BENEFITS
sra�e Form aa�oe (rts i s-oe7
•� � Prasvibetl by ihe DepanmeM of Lod Go�emmeen Finance
`, FiI�@ Maf�,
Infwmal'an wntained in tha tloaiment is CONFIDENTIAL pursuanl lo IC 61.1-12-9 and IC 61.1359. Mp i`t [� �2
INSTRUCTIONS: C � �� n V
To be filed in person or by mail with Iha CountyAuditw of fhe county where the property is lacafed.
FilingDates: 1J RealProperty:DunrylhefweNe�72)mwiths6e/oraDecember3fo7theyearthetleductionis(q���fLv�UNTYAUDITOR
2) Mo6i/e Hwnes assessed under IC 6 f.7-7 or manNactulea homes rwf assessed as real property: Dunrg the Mshe (12) ma�ths
before Marrh 37 oJthe yearthe detlucfion is to 6e e/fecWe.
See reverse sMe for atltldional insWClions and qualificafions.
Type d baneH reques�ed (p/ease dietk a� W f appty)
�Over 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credit
Name of appli�m /ownar ar conhact buyo�
l.+ �
b appGpm Lhe sde I I or equdade amerl If No, what is hivher euct share or interest7 H owned with mmeone oUer Ihan spoum,
i�rate wiN whom
❑ Yes ❑ No
K name on fem�d is diAarent ihan ihat of applianl, indi�ate bebr.
Name af contad seDer (applmznt must have Oeen b�rying m canfracf at Masf one (1) yearj
Ptldress d mntrad saller (nwnba aM sLeeG �; stafe, aiM LP mde) Is tha pmpeny in Question:
� Real property � Mobile home QC 61-1-n
Taxi� d'stnG Key n�mber / Legal descripiion Record number Page numbar
� � -i8-a� •.�- o�� ��o-o
U Ne propeny used ard ocwpiad prima br AssassaC value of the p'ope(ty as of March 1, wrrerit yaar (may rrof exceed f182,a30
hisThar residenm7 �� /oiOrer 65 dedaCis�, u� ff60.000/ur Ne Orer 65 CircuY BreeAEr Gedi�
.[� 7es ❑ No
Was the appGram 65 years of aga w rtrore on December 31 0( Ne year
� o�d��z
Adjusted gross income of appliwnR spouse, and any Source ot Inwme nmourrt of Income
individuals sharing ownership (ForOver 65 deduciion, income $
may not exceed 825, 000; for fhe Over 65 Circuit 82aker Credif,
income may rrof exceed 530,000 (orind'rviduals, or 540,000 /or s
manied couples).
TOTAL 5 0.00
Mave you ked fm aery other deducbonsl tl Ms, what deduGians9
� l�'es ❑ No � �
Have you filad tor Ceductions in any dher cwrtly? H ltv. what cwerty7
� Y25 �O
IIWe certify under penalty of perjury lhal lhe above and foregoing infortnation is frue and cortecl and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20 _
Signawra of apdinnt Pddress of appli�nt (numberand stroef, city, stafe, aM ZIP wde)
Signature d aNhaized reprasentative Pddress ot author'rmd eaqesentalive (numbor aM shee4 dN. �ta, and LP ca0o)
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