HomeMy WebLinkAboutAge_Black (3)"'". APPLICATION FOR SENIOR CITIZEN couNrv TOWNSHIP r�
- � PROPERTY TAX BENEFITS �
Stala Fwm 43708 (R9 / 408)
•O � Prescnbed by Ihe Departmant of Loral GovemmeM Finance
� Informalion wniained in ihis dowment is CONFIDENTIAL pursuant to IC 61.1-12-9 and IC 61.1-359. �r IC 1"(� LQ �2
INSTRUCT10N5: C��.n'b'�.�, ,
J To 6e filad in person or by mail with fhe CountyAUditor ol (he munty where the property is locafed v r\
Filiry Da�s: 7) Real Property: Dunng fhe fweNe (12) marrths 6e%re December 37 o7tlie year the tleduclim is to 6ep�g�� COUNTY q11DITOR
2) Mobile Hanes assessed urMer IC 61.1-7 or manulactured hanes not assessed as ieal property: Dunrg the MaNe (12) mon�is
before Mamh 37 o7the year the tleduc6on is to 6e e/fective_
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See reverse side7aatltlifional insWdions and qualificafions.
Type d beneH requested (plaase rheck a0 Nat aPpJy)
� Over 65 Deduction Gom Assessed Valuation � Over 65 Circuit Breaker Credif
Namaota icarit(mmarwcontrad6�ye _
i: a�r�m ma � i�ai or ea��aa ow�,an If No, what is hisTher ezaC share or interest7 N oxned vrilh someme othar Ihan spoum,
indi�ale wilh whom
❑ Yes ❑ No
If `wne on remd is ditfarant Ihan that of aOV��t ��dicate babw
Name W mrtrad seller (apd�anf musf liaro boen buy"ug m canlydG af leasf oiro (if year)
Pddress d mntrad saAer (numDer aM sbeeL �; sb�, aM LP mEe) �5 �he pmperty in question:
� Real property � Mobile home QC &7-1-n
4uing districl Key num6er / legal Eesuiptbn Recrnd number PaSe number
D�-�- a� -� -r�--ti�3-oo0: o��_oo,
Is 1he p�opeM �� and o¢upieC ' br Assesed value of tha pmpa�ty az o( March 1, cyRem year (may lrof eiceed f182.430
his/hef reSiEanm7 (or 0`er 65 detl�rl�, � 5760.000 for fho Over 65 Ciraif &eal�r CrediQ
�Yes ❑ No
Was tha eppGcan165 years ot aga or mora on Oecember 31 af the year Applrcanfs Cate of birth (mmN, day, yea� If filed by a surviving, unrtertied spouse.
prior to Ihe wrtent yeaR what was Ihe spo�se's aga at Ne time
�05 � NO �+_ - of deaN7
Adjusted gross income of appliwnt, spouse, and any Source oi Inwme Amowrt of Income
individuals sharing ownership (ForOver65 deduction, income � D. y� $ ��
may not exceed $25, 000: for the Ove� 65 Circud 62aker Credit,
income may not exceed 530, 000 (or individuals, or 840, 000 /or $
manied couples).
TOTAL S 0.00
Have you fded for arry o�her tleCuctions? It 1§s, what dedudiorvs7
� Yes ❑ No '"'� S
Have yvulJeO for deEuctions in any other cwiriy7 H l§s. what muerty7
� Yes �No
I/We certify under penalty of perjury that the above and foregoing infortnation is true and wrrect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Sign re d aPW�nt � ^ Address of aPPlimnl (mimDer arM sbeeL mY. ��. aM ZIP cotle)
I�.�--c,k_ 30 5. ; s i� k I,3 �! ;-f Z� .
Signature d auNOnzed raD�esen�ativa Pddrass of aWhorimd rapresentative (nvnbar aM sLeef. city, state, and LP code)