Age_Farris"' APPLICATION FOR SENIOR CITIZEN courrrr TOWNSMIP rena
r;�_-. - ; PROPERTY TAX BENEFITS � � �
�-- � sm� Forr� as�os �as i saa�
� �.i. Prescnbed by Ne OepartmeM of Local Govemmam Finance
ile Mark
In(ormation contained in this dowmenf is CONFIDENTIAL pursuant W IC E7.1-12-9 and IC 61.1359. MAY 2 t� 2��
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INSTRUCTIONS: C.�.n " V
To be filed in person or by mail with the CountyAuditor o/ the counry where the property is located.
Filing Dates: 7) Real Property.� Dun� Ihe hveNe (72) marths 6efwe December37 o7the year (he qed��lt iite ��fi�c�DITOR
2) Mobile Homes assessed urMer IC 61.1-7 or manu/actured homes raf assessed a�''r e pl peity Y)unrx� Ihe hvelvs (72) months
6efpe Marrh 37 of the year the tleductlon is fo be eRactive.
See reverse sde fa addifional insWdions ernf qualifications
TyVB d benefi reGuested (please rhetk a9 Naf aPPNI
�Over 65 Deduction 6om Assessed Valuation �er 65 Circuit Breaker Credit
Name
f avned wilh someona mhe an spouse,
indica�e wi�h whom
❑ Yes ❑ No
H`tame on remrd is diflaren� than Ihat W appluanL irM'rcale bebw
Name ol cantrarl saller (appficant mvst hava be� Ouyiig m canf2ct at least orm (iJ yeaQ
Addrass of mntratl seAer (numbrr aM street, ci(y, sWM, a� ZIP coCe) Is lhe pmpeity in question:
al properry ❑ Mobile homa (IC 6-74-�
7��g �' Key number I Legal dewiptian Record numbar Page number
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Is Ihe pmpaM usad arW ocwpied primarJy lor As5e5saE valua o( Ne property az ot MaRlf 7, wrtent year (may rat exceetl E782,130
his�her residenw4 tor O�er 65 dedurliory or 5f60,000 /oi tho Owr 65 Circuf &eaker C2dLy
es ❑ No
VJas the appGmM 65 years o( ape w mora on Oec ber 31 af Ne year
Have you filad tar atry othar deEurrions? If lbs. whal deE�rJions?
� Yes � No
Have you f9eO for deductions in anY olher courity? H Ms. wtiat courtty?
� Yes ❑ No
IM/e certify under penally of paryury that the above and foregoing infortnation is true and cortect and lhat tha applicant was a resident
of Indiana and owner of the aforementioned property on March t, 20
Signaturedappf Pddressofapplirant(mimEOrarMstreeC'�'.Y.�m,aMZlPwdo) ���0
� �y![J'i.t/v`�-a. To� cSoLL'R^� j�n�tc� .j� t�Rl.�cc='w��1v
Signmure d aulhorizetl representative Adtlress of author�d reprasentative (numbrlalNShee4 u�Y, sfatv. end LP cade)