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APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP � YEAR
. PROPERTY TAX BENEFITS y
S--' Stab Form 437081R9 / 9-OB)
� � u Prasuibed by Ne DepaRmem of Local Govemment Financa
de ark��
IMormatiom m�talned in this tlocvment is CONFIDENTIAL pursuanl to IC 6-1.1-12-9 anE IC Crt J35-9.
INSTRUCTIONS:
Ftiirg fiDates.• �r 7J Re� Propeify: Dunng uthe AveNe (12) mavrths beforee Oece �� �ol fheeyear the deducfion is to be efrecWeEP � O 2��9
2) Mobde Homes essessed urMer IC 6-1. 7-7 or manWactured havnes rrof assessed es real propeRy: Dunrn�`the�Ne (72) montlis
B
belore Mart,t� 37 07 fhe year the deduction is to be eflective. a"� ��
See ieverse sde for adtlaional inswdions end qualificatims. C'�BSOlV Cn���,
Type of benef.t repuestetl
Over 65 Deduction 6om Assessed Valuation
Name a( apd�M (owrar ar wn7acf Euye�
�.�., i �!-
Is aDG��m�i ihe �(e lapal or
�Over 65 Circuii Breaker Credit
ahare w inte�est9 H owneC with somawa olher than spousa,
indifate vnlh whom
� Yes ❑ No I
I( nama on racwtl is diRa M than Nat d e0diranl indicete bebw
Name of cont2d eeAer (eq�l'zanf must fbw Eoon Ouying on contrep at leasf oire (1) yea�
Tanirg distrid
shae4 cr(y. sWfe. ard ZIP wde)
Key number / Legal Cescnption
�, �,.D�o?3"-/a/-DGO. 03a-
I5 ihe D�OeM used anE occu0ied pnmarily br
hislner residenreT �.y
IVI Yes ❑ No
7T
Was lhe apWkaM 65 yearn of age or rtrore on DecemDer 31 of Ihe year
prior Io t�e airtaM yeaR �y
Uq Yes ❑ No
Adjusted gross income of applican pouse, and any
individuals sharing ownership (ForOver 65 deduction, income
may not exceed 525.000; /or the Over 65 Circuit BieakerCredif,
income may not exceed S30,000 lor individuals, or 540, 000 for
married couples).
for a(ry a7rer deduclona7
❑ Yes
Have you filed lor dedud'wna in eny dhx caurM1y7
� Y85
� No
� No
prooerry in aua5tion:
7 Real property � Mobile home (IC 6-7-1-�
Record numher Page num6er
0.ssessed value of Ihe o�Perty as o( March 1. cartem year (may not axcoatl SiB2.d30
lor Oror 65 OetluCian, ar 5f60.000 !or Mo Ovor 65 Circuit &oaker Credi�
— / - �/
Source of Inwme Artrount of Income
IS
It Ws.
g .
TOTAL � 3 /z�j,�l.�' 0.00
I/We certify under penalry of perjury lhat the above and foregoing infortnation is true and correct and that lhe applicanf was a resident
of Indiana and owner of the aforementioned property on March 1, 20 '
$ignelure of appticam Add�ass of eoP����1 (numboiaM stroet, ciry, sfafe, aM ZIP cade) - .
° • 2. d .� u% , �a-�,e� �C�- T,c� �f ?�(
SignaWre uthoerseE(aCrvsentative Pddreseotaultroraedrapresentative (n�mDera�s✓ce[,eity.5tafe.anOZ/Pcrotlo)
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