HomeMy WebLinkAboutAge_Webb� APPLICATION FOR SENIOR CITIZEN e� � Y�
. PROPERTY TAX BENEFITS
` '' StaroFOrm437081�19-08)
Presfii6ed by Ihe Depar�mertl ol local GovemmeM Finarice
Informatiom m�tainetl In this tlocvment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1J35-9. HP R Q�p .26�q Matk
INSTRUCT10N5: C ���n�
To 6e filed in persm or 6y mail wtth fhe CountyAUditw of the county where Ure properry is locafed.
Filing Detes: 7J Reel Property: Durirg lhe (weNe (72) martAs belore December 37 0l fhe ysar fhe ded�6��f�iyaAUDITOR
2J Mo6He Hanes assesse0 uri0er IC G 7.7 J or manulactured homes no( assessed as real property: Dunng the hveNe (12) monMs
be/ae Mart� 31 0/ fhe yeer the deduction is to be eHective.
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See reverse side la aCdifional lnsWUions eM qualificetions.
rypa of beneft reoue5ad (pl rheck a9 Naf appl�
� Ove� 65 Deduc[ion from Assessed Valuation Over 65 Circuit Breaker Credit
Name d aDdkant (owner ar cmtracl Du)eQ
(N
b aoPli�rtl the ada lepal or epuitaGe ame(7 tl No, what is hisiher exacl are ar interest? tl owned with mmeone oiher than sDOUSe,
indipte with whom
❑ Yes ❑ No
M name on record is diflerar�t Man thai o1 epplirant indicate bebw
IJame d comae sener (aavrKenf must nnw eeen e�yinp a� cmVacS af reas one (7) yea�
Pddress W contrad setler (number arW sbee7. ciry, slale, aM ZIP mde) Is the O�oerty in Queslan:
eal property � MoDile home QC 644-�
Tazing di ' ` Key numher / Lepal dasuiplion— Record number Page num6ar
� �� 'Q
Is Ihe proparry used and ocwpied rily br Assessed value of �he Dmoarry as of Mam1i 1, wReM year (may rrof exceed S� 82.dJ0
hivher rasiden�7 �rOrer 65 deduction, a S f60.000 !w Ne Over 65 Ci2urt &oekar CradiQ
es ❑ No
Was tha a0d��165 years ot age w more on December 31 W the year If filed by a survbin9. un.�na�ed spouse,
pdor to Ihe wrram yaaR � �'� what was ihe spouse'S age at tFe time
5 ❑ No � „/ otdeaN?
Adjusted gross ineome of applieant, spouse, and any source oi �ncome nmount ot �ncome
individuals aharing ownership (FOrOver 65 deductbn, income I S
may not exceed 525, 000; !or the Over 65 Circui[ Breaker Credif.
income may rrot exceed 530,000 for individuals, or 540.000 for ' S
mamed couples).
ITOTAL I S `%o� % 0.00
Hava you fled for arry dher deductions? I( Ves, what deduGions?
�Yes ❑ No
Have you filetl for deductions in eny dher muMy7 If Yus, what counry?
� Yes No
I/We certify under penalty of perjury that the above and foregoing infortnation is true and cortect and that tha applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20 _
SignaWrB of apd�ts Addrass of a001ipr.t (number a� sbaot. cily, SfatB. �1 �_//
y�� s �,;,
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Signatu'e of euU�arized raD�asemative Pddrass of euthonzed reGresentative (numDer and sueef, city, stafe, and LPcode)