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• � APPLICATION FOR SENIOR qTIZEN couNTV rowNSxiv renR
� PROPERTY TAX BENEFITS
State Fom q]09 (R1014-0B) �
�I• PreuMea o me
Y �Oe`Nbn� d Loral Gove�evrcn� Fwrce
File � rk
In/ormation comainea in Ihis aocumenl is CONFIOENTInL pursuanl to IC 61.L12-9 anE IC bt.t-0b9,
INSTRUCJIONS: DEC G � LO�O
To be fJetl in perapn ur by ma/ wrth fhe CounlyAUC4or olNe county where the propeRy is bcaled.
Favg Daresr 1) Real Property: Dutlrg Me nveroe (12) monAS belae Oecem6er 31 0l the yeer �ne eaeuccon is ro ee eflecwa.
2) MobdeHanesassesseduMeNG61.1-7wmanWacNreChwnesnotessessedasrealpope.ry:OunnglneMeloe�ldJ s
Oelole MaNi 31 0l (�e year Me EeOUCtbn is (o Je e0e[Ine. �G� ��
See reverse Stile lor atlCP.iOna1 v15LUCIrons an0 puatwRations.
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rwe a c�,�.w reo��:m i�a.0 aK�.. ��,� „„J„�
❑ Over 65 Deduction from Assessed Valuation � Over 65 Circui� Breaker Credil
n..a m,>au euye.y
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aook+n�Ne:okk5alnecu�latleo.nelr IIHO.
❑ Yes � No
�ame m rca.a �s aecrem w� mn o� a�m. �mra,. �,..
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muv Mre Geen dryvg m mro'aq al ban me (1) yvarJ
(mn+Or iM s4epl. ply. Yale.
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el IS T! pope�y in pueslpn:
�p Real property ❑ AbOie nome pC Gt-v-7)
�e. � lny aesa�ocm Feme mi. eer Pope numoe.
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� Yes ❑ No
Wss tl�e app6on165 Yean of aqe o.we on DacemOer Jl d tM year
p�' 10 LM Y=a� W R Y! fiR� 41C dM WYeGP'!
� res ❑ No
Atljusted gross income of applicant, spouse, anC any
IndiWduals sharing awnership (FOr Over 65 deduction, income
may no( ezteed 525,000; (a Ihe Over 65 Ciroud &eaker Credit,
inrome may no7 erceed 530,000 /or in0ividuals, w Sa0,000IOi
mamed couA�es).
yo, r,ea m, any r. er aee�mm:?
❑ Ves � No
�� rw �.�o �o ���: n a�y wm wun:v' I u xa...nai caumy+ .
❑ Yes � No
WJe certify under penalry ol perjury that Ihe above and foregoing information is tme and wrrect and Ihat the applicaN was a resident
of Indiana and owner of the aforementioned pmpeny on March 1, 20 _
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