HomeMy WebLinkAboutAge_Fortner (3)"' APPLICATION FOR SENIOR CITI2EN
, PROPERTY TAX BENEFITS
Siate Fom� 43708 (R919-0B)
�� u. � Presrli6ed 6y the Deoartment of Local Govemmerrt Finance
In!ortnetion containetl in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 antl IC 6-1.1-35-9.
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INSTRUCT10N5:
CO NTY � � W S IP' � Y R
D C 1 0 201�
File Mark
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GIBSO": COUF!TY AUDITOR
To be fifetl !n persm or by mail with the CounfyAudifa ol the munry where Ute property is loca7ed.
Filirig Dates: 7) Rea/ Property: Dunrq the tweNe (72) months be/o�e December 37 of fhe ysar fbe deducfion is to be eBecfive.
2) Mobile Homes assessed urMer IC 64.7-7 ormanu/actured homes rrof assessetl as real property: Dunng fhe MsNe (72) months
6efore Mardi 37 0/ the year fhe deduc6on is to be eHecWe.
See reverse side fw atlditiona/ inshuctions aiM vualifications.
TYPa W beneft reCUestetl (dea rheck a➢Ilut aPM'1
Over 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credit
Name of aO�M (oM+iM or cartrect Duyo�
_/
Is ap ihe sole legal or eQUiWGe owne(! If No, whai is Ns/her ezact s�are or interest? If o-xneC wiih sameore other than soouse.
V1d�WlB N1lh W:IOT
Yes ❑ No
H name on `ewrd is diAarent ihan thal af aodica�4 ��Eicate bebw
Name W romrzct sa0er (apW'Itanl musf hava Dcon b�ying m can4act at loa5 ono /1) yca7
Pddress at mntrad aeller (numberarx/ sbeaq crty, sfalo, eM ZIP cotle) � Is the pmoerty in ouestion:
�Real pmperty � Mobile home (IC 644-n
Tazing di ct Key number / Lagal Eescno�ion Record numbar Page number
" •/d-/�,/O/-a�0. 25��-
I5 Ne proparry u5e0 and occupied Orimanly br hssassed value of ihe pmperty as ot March 1, wrtant year (may rwf erceed 5182,d30
his/nar resiEence? kr Over 65 tlaductian, a 5 f 60.000 for f�e Ovr165 C'ucuit &eaker Credi�
� Yes ❑ No
Was the ap0���1 fi5 years of ege or more on Decembar 31 of Ue year Applipnfs data ot birth (monlh, Cay. yea� If filec by a surviving, unmamed s�ouse,
orior ro the airtaM yea(! wcal was ihe s0ouse's a6e at lhe time
afdeath?
� Yes ❑ No
Adjusted gross income of applicant, spouse, and any Source of �ncome � Amount oi Income
individuals sharing ownership (For Over 65 deducfion. income I S
may not exceed 525,000; lor fhe Over 65 Ci�cuit Breaker Credil,
income may not exceed 530,0007or individuals, or 540,000 for I I S
manied couples).
TOTAL I S 0.00
Hava you filed for arry othar deductions? If Vas, •xhat ceductiors?
�s `� Yes � No
Have }rou Gied lor deduc6on5 in any oiher counry7 If Yes, wnai county?
� Yes � No
IIVJe certify under penalty of perjury that the above and foregoing information is lrue and correct and that the applicant was a resident
of Indiana and owner of the aforementioned pioperty on March 1, 20 _
Sgnature of aOW��� ACdress of aoo�imnt (nom6cr antl strcet, ci.y. s;alo. antl ZIP wde) I
W
Signat ra ot auNOnzed reDresentative /cEress ol autnorizec re�resentative (number and s:met. ciry. slafq and ZlP cotle)
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