Age_Schumacher� APPLICATION FOR SENIOR CITIZEN � ca N � o Ns a � re.nr: i
y� PROPERTY TAX BENEFITS
'�,I• Sdre Fortn 43]OB (R919-0B) , �[� 1 D 2�0�
�'� Prasai6ed by tha Depanment af Local Govemmem Finance
File Mark
Information wntained in this document is CONFIDENTIAL pursuant to IC 6-1.'i-'12-9 antl IC 6-1.'135-9. �laµ /�
N
wsrRUCnorvs: �,gspp! COUNTY UA DITOR
To 6e filed in persar or 6y mail with fhe CouMyAudrta ollhe wun y where the property is /ocated.
Filiry Dates: i) Real Property: Dunrg the tweNe (72) months be/ore December 37 olthe ysar the tleduction is fo be sHecWe.
2J Mobife Homes assessed urrder IC GiJ-7 or manulactured homes rrot assessed as real properfy: Dudng the twelve (12) months
6efore March 31 0l fhe year the deduclion is to be eNective.
See reverse sitle fw adddional insfructions arM qualificafions.
Type of benefl reCUested (pleaso tl�ock a0 Nat apply)
� Over 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credit
Name
oreQUYaWe owne If No, what is hisPoer exact share or mterasi7 It ownad vntn mmeor.e
n indicata with w`om
�es ❑ No I
1( name on reco�d is diflerent lhan ihat of aodifan� indicate below
se0er (appFCant must haw Dem ovyirg on
� I Pddrass of mntrae saller (numbaanE sbae(, crty. stafo, arM ZIP codo)
Key number I le9al descnotion
and occupieC
.,
❑ Yes ❑ No
YJaa the ao0��m 65 yaars of aga or more on Decamber 31 of Ihe year
onor to the airtam yeaR
� Yes ❑ No
Adjusted gross ineome of applieanR spouse, and any
individuals sharing ownership (FOrOve� 65 deduction, income
may not exceed 525,000; for the Over 65 Circuit Breaker Credit,
income may not exceed 530,000 tor individuals, or 540,000 (or
manied couples).
Have you (led fw a..y olher dedudim:si
Have you filed Iw daEucUOns in any
� Yes ❑ No
� Yes � No
proDBrty
soouse.
I prope .ry � Mobile home (1C 6a4-�
num5er PaganumSer
Assassed value of tFe OroOerty as of March 1, currert year (may nof escactl 5f82.d3o
:or Owr 65 dMuCion, or 5 t60.000IOr l�o Ovcr 65 Cucuit &oakor CrediQ
�a g�
INJe certify under penalty of perjury lhal the above and foregoing information is �rue and correct and that the applicant was a resident
of Indiana and ownei of the aforementioned prope�ty on March t, 20
�
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.
reDresemative . Address o( autnorizec :e�resenUtive (numberand sbeet, cify, sfate, and ZI codo)