Age_Ayer_ ," APPLICATION FOR SENIOR CITIZEN COUt�7Y TOWNSHIP venFi
3. PROPERTY TAX BENEFITS - _ ,
.'. f State Fwm 43708 (R9 / 9-OB) y
•� u� � Presaibetl by Ne Department ot Loral Govammam Financa p
� B
� de Mark
Informa�ion containetl in Nis document is CONFIDENTIAL pursuanf to IC G1.1-12-9 and IC G1.1- .
�
wsrnucnoNS:
FEB 13 2012
To 6e filed in person or by mal wHh the CountyAudita o! the aounfy where fhe property is located. ��
Filirg Dafes: 1J Reel PropeRy: Dunng the tweNe (12) mmths 6e/ore December 37 0/ the yeer the tle(lucfion �s �e effectiVe.
2) Mo6ile Hanes assessed urrder IC &7.7-7 or manu/actured hanes not assessed as real property Duthq D�� (12) mmths
6e/ore Malrh 37 07 the year fhe deducG'on is to be eNective. G�gSON COUNTY A
See reverse sMe7ararltlifional insWdions and qualifications.
Type d beneN requested (please Meck a0 Nat apply)
� Over 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credit
Nameofapplica(n arcartiactDuye�
Is a00�m tha legal or aquitade e(! ' It o, what is hisiher exad shara w interest7 If owned with mmeone olher lhan spouse.
indiole with whom
❑ Yes ❑ No
It rume on ramrtl is dilfetaM Ihan that of appin'ant intlicale bebw
Nama d cani2d seAar (a�canf must have bc� buyirg m cmtraG at /east one (1) yearJ
Pddress d conhan mllar (numDer aM sbae4 ury. stafe, arM ZIP code) �s Ihe pmperty i^ question:
al pmperty � Mobile home (IC 6-74-�
iuing dislnct Key number / Legal dasuiption Record number Page numbar
a�-/,�-ZO -/O/-000 . Do •00�
Is me v�weM �sm and oca,piad arimanN mr wcsessed vawa or me v�aeMy as o, Maml, 7. u,Ram year (may nw e+ceed s�EZA7o
his/her residenw7 for O�er 65 deducliwy a ff60.000l0� Na Over 65 C'undf Broalmr CrtMiQ
❑ Yes ❑ No �8'��
Was ihe epp6ran165 years of aga a rtore on Dacembar 31 of ihe year Appfimnfs date of birth (maM, day, yearJ If fdad by a arvning. unmartieC spouse,
o�o� to me a�rrem yean �hat waz the spousa a age at Ihe time
❑ Yes ❑ No oreaaUz
//- /
Have you fJed M arry Whar deCucUOns7 if 1§s. whai deEucfiortsl
� Yes ❑ No �S
Have you Ned tor daductions in any dher munry? If 14s. whal cwnry7
❑ Yes � No
I/VJe certify under penalty of perjury that ihe above and foregoing information is true and wrrect and that the applicant was a resident
o( Indiana and owner of the aforementioned property on March i, 20 _
Signaturedapplusm Addressofapplirant (numberarMsboo4�:��.�ZlPcode)
a-�5 N- C�,�ie�- �rc�,-�e�Sc.�� ��u`�
SignaW � auU�orized reprasen � e Address o(au�har�d tapresenlativB (numbefaMSLOeL �1: sfa.G anE LPcode)
\