Age_Reed.
APPLICATION FOR SENIOR CITIZEN c � owr�� vena i
PROPERTY TAX BENEFITS � h
State Fortn 63708 (R9 / 9-0e) �/'
���• Prexnbed by Ine Depanmerit of Loral Govemment Finance
ANK �eM��iU
Informatiom m�tained in this document is CONFIDENTIAL pursuant to IC &1.7-12-9 and IC 6-1.135-9.
INSTRUCTIONS: �yy�
% �ra�.. ,Gr�,
To be filed in person or by meil wiN the CouMyAUtliiw o/ the county where fhe property is located. Q O'
Fil/rrg Dates: 7J RealProperty: Dunrg the tweNe (12) mmfhs 6efrne December 31 o/fhe yearfhe tleduction �'���iA��NTY AUDITOR
2) Mo6ile Homes essessed under IL 67.7-7 ormanNactuied homes irot assessed es real property: During !he hveNe (72) months
belae Mardr 37 0/ the year fhe detluction is to be ellective.
See reverse sMe foradd"dionel insLUUions erM qua/ifications.
rroe or ee�ef.f recuas�ea Idoue a,ock e6 u�a� avdrl
❑ Ovar 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credit
(owirer w cmliact ouye�
� �
Is aoolkaM lhe sola lepal epuitade owneR If No, wtiat is hisfner exad shara or interasl?
❑ Yes ❑ No
H name on recrord is diflareM tlwn Nal d eDd'Mar.t indicate bebw
Name of mrrtad seller (tpyicanl must havc Deon
mntrsa
� Taxing distnd �
aM streef, city, sfate, and ZIP coda)
Kay number / Lepal
Ia� - �8-0�
�Is bhe o�oOeM used and oauvieE o�many for
his/ner asitlence7
�Yes ❑ No
Was lhe app6caM 65 yeero of apa or mwa on December 31 of tha year
orfor ro the a,rram rean
�Yes ❑ No
Adjusted groas income of appliwnf, spouse, and any
individuals sharing ownership (ForOver 65 deduction, income
may not exceed 525,000; (or the Over 65 Circuit Breaker Credit,
income may rrot exceed 530,000 for individuals, or 540,000 fo�
married couples).
Have you (deE tor a(ry
,�YES
Have yo� filed tw CetlucGOna in any othar caumyl
� Yes
Y��
If owned with somaona o�her than 90aise.
indifata with wtiom
Is the p�o erry in Question:
Real property � Mobile home (IC 6-74-�
iption - RecorE num6er Page number
-303-dUO,/�, -p�. a--
Assessed value of the properry as of March 1, wr.ert year (may irot orcoe0 5182.130
for U.er 65 tletlurlian, w f 160.000 for Na Over 65 Cuc�if Biezkw Cretli�
INVe certify under penalry ot perjury thal the above and foregoing informalion is trUe and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March i, 20 _
�na�ure oLawrKaM / � _ MdBSS ot apP�r.t (numDwenC stroet, ciry, stafe, aiH ZIP wEe)f n
��_ ( 0 Jk u � "' U/� .
Siynature of auLhonzed rmemative Mdresa oi eWhorizad rewesentativa (numEwaM sflooC ciry. siafe, and LP code)