Age_Riley�
APPLICATION FOR SENIOR CITI2EN
.y. -. • pROPERTY TAX BENEFITS
` Stafe Fwm d3708 (R9 / 9-08)
u�. � PresaibeC by Ne Departmenf of lacal Goremmem Fir,ance
COUNTY I TOWNSHIP � YEAR
File t�k'� �
Informa[iwi contained in this doament is CONFIDEN7IAL pursuant to IC 6-1 J-72-9 and IC 6-1.135-9. -� `��
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INSTRUCTIONS:
To be filed in persm or by mail wrth fhe CountyAudita o/ fhe munty where Ne property is located p0a
Filiry Dafes: 7J Real Property: Dunrq fhe fweNe (12� monfhs belwe December 37 0/ fhe year the deduction is fo be e8ect`q\� (' 3 ��
2) Mobi/e Hanes assessed urMer IC 6-7. 7-7 or manu7actured homes not essessed as real pmperfy: Dunng NACfi eNe (72) montlis
6e%re March 37 0/ fhe year the detlucBOn is (0 6e eNective. /L �N
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See raverse side fa additiona/ inshuctions arM qualifications. 'r� P�� P`
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Tyoe of benef.t �uasleE (please rheck a0 Nat appiy) G`BS�N GO
Over 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credd
Name of applicaM (o�vr�rp�artracf b�yeQ ` �
� J F
y � ��Q , l E
Is ao0licam tha sNe legal or eQUitable owneR If No, whel is nisiher e�act share or interast7 I ownad witn someone o�her than spovse,
indif2le with whom
❑ Yes ❑ No I
on rewrd is diflarent Ihan ihat of aodiGant, inCicate below
Name ot mnlact seller (apd��anf must havc 6cen 6uyiig on cmf2ct at leasf ono (1) yca�
Pddrass ot mnirdC seller (numberarrd sbeel, ciry, sfaro, a� ZIP code) �s Ihe vmoerty in ouestion:
� + �Real property � Mobile home (IC 6-7-7-�
�g d/isj+�� K� yn�r l�descnptiw� /�'/n � R numhar Page r,umce;
T/IY//rC"1�C�-VJ P d/v Q.—�.IXY(_��
Is ihe property useE anE occuoied o�many for
hisRierresMenca?
Yes ❑ No
V7as the applicant 65 yaars o( age o: more on Decembar 31 ot tne year
ptior t0 �he aureM yea(1
Yes ❑ No
Adjusted gross income of appliwnt, spouse, and any
individuals sharing ownership (FOrOver 65 deduction, income
may nof exceed 525,000; for the Over 65 Circuit Bioaker Credit,
income may rrot exceed 530,000 for individuals, or 540,000 for
married couples).
Have you fJed for ary olher deductior.s?
� Yes
Have yoa (ded fw dedudons in any other cwnry7
❑ Yes
� No
� No
Assessed value of the omoarty as of Ma¢h M1, curzent year (may not exceed 5:82430
h/ Owr 65 tladuction, a 5160,000lor No Ove� 65 Cilcuil Broaker CrMi:)
�-
If ffis, what Geductions?
It lps, wnal couniY?
IIVJe certify under penalty of perjury that the above and foregoing information is We and correct and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20 _
� Signature eppficanl PdEressotaoPlimnt (numDeranCSWeqciry.staro.andZlPmdo)
' � � �; � ' . � -..�
� Sipnatura d aulhonzed represan aW AEdress of authonzatl rewesentative (numbcranE ,iaef, ci , state, and Z/P code) �/J/ �
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