HomeMy WebLinkAboutAge_Jones� APPLICATION FOR SENIOR CITIZEN c wNS P � r i
� PROPERTY TAX BENEFITS
` ' State Form 43708 (R9l 9-08)
P�escribed by the Depanmarrt of Local Govemmem Finance
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Infwrtiatiom m�tained in this docurtrenf is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 61.135-9.
WSTRUCTIONS: d�// �
To be filed !n person oi 6y mail with fhe CounryAudifa o7 the �un y where Ne property is locatetl. ���c �r��,1COUN7Y j�UD�TOR
Filing Dafes: 1) Real PropeRy: Dunrg the tweNe (72) monfhs befae Decem6er 31 0! the year the deduction is to 661f1fdsnrB7
2J Mobile Hpnes assessed urrder IC 67.1-7 ormanulacture0 homes not assessed as �eal pmperly: Dunng the M1veNe (12J months
be/ore Ma� 31 of the year fhe detluciion is to be e//ecfive.
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See reverse side /w adddional insUUGions and Qualificalims.
Type W 6eneft reQUested (plee Mxk e0 fhat appj�
Over 65 Deduction 6om Assessed Valuation Ovar 65 Circuit Breaker Credit
Name d apd��� (�� a' �u'rt+ecl DuyerJ
. �
Is aDGtitarit the sole lepal or eQUilable owneR It No, w�at is his�har aG shara w interest7 H owned w�ih mmeone olher I�an spouse.
intlitate wit� whOm
❑ Yes ❑ No
H name on ramN is diflaeanl Man Ihst d appikan� iMicete bebw
Name af mitracl saller (applicant musf Naoe Oeen Duying on conVatt af least orie (1J yearj
IP4dress W contrad saAer (numbaaM streeG cify, stato, aM ZIP wde) Is iha p`ooerry in Questbn:
� Real properry ❑ Mobile home (IC 64-7-�
Tazinp distnd Key numhar / legal descnption RecoN num6er Page number
� - --I�= = - 03_ - U0._3_ -oa � �
Is ihe O�PaM used a�k occuoied pnmariy for Assessed value ot lhe pmPe�ty as at March 1, cumem year (may rrot erceed 5182.a30
hisRier iesidenw? lor O�er 65 doduUion. m 5760,000 /or Ne Ovor 65 Circuif &eeker Gedi�
es No
Was Ihe epp&sM 65 yaars of ape or mwe on DecemEer 31 o e year ApoGCanYS date oi birih (mmfh, day, yearJ If fiied oy a surviving, un.�remeC spouse,
prior to Ne artent yea(7 wtiat was lha SDOUSe 5 age at ihe time
s ❑ No otdeam?
Adjusted gross ineome of applicant, spouae, and any Source oi income nmount of income
individuals aharing ownership (FOrOver 65 deduction, income I S '�
may not exceed 525, 000; for the Over 65 Cirwit Breaker Credit,
income may rrot exceed 530,000 for individuals, or 540,000 fw I S
mamed couples).
ITOTAL I S 0.00
Hava you filad tor a.ry other tleEucEOne7 It Ves, what ded�ciions?
Yes � No
Mave you fiied for deductioru in eny ather mu:rty7 It �bs, what munry?
� Yes No
I/We certify under penalty of perjury that lhe above and (oregoing information is lrue and correcl and that the applicant was a residenl
of Indiana and owner of tha atorementioned property on March 1, 20 . '
1 SigneturadapplicaM AdErBS5ofa0P��mn1 (numbera�strcoLCiry.slate,aMZ/Pmtlo)
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Siqnatureofeuthaiz rep�eseMa' e Ad ssotaulhorizedre0�asentative (numDerands✓ecCCiry,slato,andLPcode)