HomeMy WebLinkAboutAge_Hayhurst� ,"' o APPLICATION FOR SENIOR CITIZEN I�� I�
t!-. _ : PROPERTY TAX BENEFITS "�
•� ' Spla Fortn 43708 (R9 / 44B)
� u� � Prascnbed by the Departmerrt o( Loral Govemmem Financa
Informatiom m�fained in this doaiment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 67.L3S9.
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COUNTY TOWNSHIP YEAii
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Fle Mark
AUG 2 2 2011
INSTRUCTIONS: C �
To be filed in persar or6y mail with the CountyAudilorolthe county where fhe property is located.
Fili� Dates: 7) Real PropeAy: Dunm� the lweNe (72) monNs 6efore December 31 0l (he year the deducfion is,(q� gflN fti�rv�e1.
2) Mobile Homes essessed under IC fr7.7-7 or manulactured homes raf essessed as real property unrg P+9�SeY(��i��
6e�ore March 37 0( Ihe year the deduction is (o be elfective.
See reverse side fof atldilional insVUdions arM qualifications. /� �, (
Typa d 6eneft teQUesied (p/ease rheck a9lhat appl�
�C Over 65 Deduction from Assessed Valuafion ,�Over 65 Circuit Breaker Credit
NamB d applirant (awrior w cmlydcl6uye�
1�� i
Is applimM the sde legal or equilaWa owneR If No, what is hi r ezact share or inlerest'! It owneC vnlh someme oiha� lhan spwse.
irMicate xith whom
❑ Yes ❑ No
If name on recad is diRarant than ihat ot apd�ni inEiwte belox
Name of mntrad sellar (appficanl musl have been buy'ug m cmlracf af leasf o�
Pdd(ess of mntratl mller (number and sbeeL �1: sGln, arM LP cotlo) Is Ue property in pueston:
oeM used anE oxupied P�ariN br
� Real property � MoDile hwne QC 67-1-�
Key numbeN Legal description Record number Paga num6er
��-a3 - o�-aoo-000 a3 -009
Pssessed valua of tha pm0arry as oF Marrh 1, wrterit year (may rwt exmetl f182,430
Ior O�er 65 tleducfion, uf 5760,000 Por Iho Ovor 65 Cucuit &eal�rCrt.HiQ
��y�e„�Wn��.�, �Yes ❑ No
Was Ne aOP�M 65 yaars of age a more on December 31 of lhe year
prior Io Ne airteM yea(!
�es ❑ No
Adjusted gross income of appliwnt, spouse, and any
individuals sharing ownership (Fo�Over 65 deduttion, income
may nof exceed 525, 000; for the Over 65 Circurf B2aker Credit,
income may rrot exceed 530, 000 /or individuals, or 540, 000 for
married couples).
ya� fJaE (or arry other detlucfions7
� Yes
Hava yau fJed for deductions in any olhar cwrity?
❑ Yes
� No
� No
IIWe certify under penalty of peryury that the above and foregoing information is true and corzect and lhat the applicaN was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20
Signatura d appih,aM Address of appfrant (number and sbee4 dN, sbb, and ZIP mEO)
r . . . , / /1 , . . ,. _ . � n �. / � . . �
. �7
� I Signature d a�a�d ieprasenta6va � I Address of aNhor�tl reptasan�ative (numdrl arid afrtiet, tity, s}ate,
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