Age_Johnson:
"' R APPLICATION FOR SENIOR CITIZEN
= � PROPERTY TAX BENEFITS
� "! State Fortn 63708 (R9 / 408)
� Prescnbad by �he DeOan.ment of Local Govamment Finance
Infortnatiom m�tained in this document is CONfIDENTIAL Wrsuant to IC G7.1-12-9 anC IC &1.7-35-9.
INSTRUCT70N5:
COUNTY � TOWNSHIP � YEAR j
(
File
MAR 16 2011
To be filed in person or by meil wiUr fhe CountyAudrtw of fhe county where Ure property is locafed. C. �J,
Filirg Dafes: 7J Real Property: Dunrn� the fweNe (72) morrths befwe Decem6er 37 o/fhe year the deduction is to be efrective.
2J Mo6ile Hwnes ascessed urnder IC 6-7.1-7 or manulacfurad hanes rrot essessed as real property: DunrQ�v���1NTY q
6e%re March 37 o7fhe year the deduction is to be eHective. V UDITOR
See ieverse side 1w additionel insWCtions aM qualiflcatlons.
TYOe d beneH reauesfed (pleese rheck eH fhaf appl�
Over 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credif
Name of apWi rit (owr�er w cmfrad buyeQ
l�x�flc� c¢.�<„"'__ —
is applimM the sde legal or eQuitaWe owneR If No, what is hislher exacl st+are or interest7 N owned with someone aher than spouse.
indipte wilh whom
❑ Yes ❑ No
If name on recortl is ditferarit �han Na� o( aDpfinnL intlicete bebw
Name W contad seller (a�wnt musi nave beon buy'vg m contraa at Mzst one (t) yae�J
Md�ass of contrad seller (m�mbm aM stree4 cily, sdfa, aM ZIP wde) �s the pmoeM � auestion:
Real property � Mobile home (IC 6-74-n
, Tazing distdcl Kay number I Legal descriplion RecoN numbar Page number
- �a-aoo. S��- 9
Is Uie uopeM usad and occupad primariy br 0.ssessed value of the D�oDerty as of March 1, curtem yeer (may irot e+ceed 5182,d30
his/ner residenw7 torO�er 65 detluctan, a 5160.000 /o/ No Ow! 65 Circurt Breaker Getli�
� Yes ❑ No
Was the eDO�ani 65 years of age w more on Dece�r.Der 31 of the year
�
Have you filed fw a�ry olher deducEms7 I( Yas, wnat daducUOns7
� Yes � No •
H3vB YW filBd 7IX CBCIiC10�5 ip eny OthBl COUlIt)'? If ffi5. x�haf county?
❑ Yes ❑ No
I/VJe certify under penaly of perjury that ihe above and foregoing information is irue and corzect and that the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20 �_
� SignatureWaOd�M Pddrassofap0�irant(numbmandsWOt,ciry,sWte.aMZlPmde)
� G� �. ,
�gn tura of euthorized O�e Addrass of euthorizad rapresentative (numOeraM sUOOt. ity, stafo, and LP codo)