Age_Ingram�
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APPLICATION FOR SENIOR CITIZEN couNrv � TOWNSpIP {�-Yenn
,.-rt ! PROPERTYTAXBENEFITS ¢ ' %.-., tj �1
` ; Spte Fortn a370B (R91408) .• 6 �. �,^ :'.�.-1'
Prasuibed by Me Departmer.t of Local GovemmeM Fi:ance 1L
• Fil@ tvtarl��u$
Information wntained in this tlowment is CONFIDENTIAL pursuant to IC 6-1 J-12-9 and IC 6-7.135-9. Ut L 1
INSTRUCTIONS: ''�j
To be filetl in persm or by mail with fhe CountyAudita o/fhe county where the property is /ocatetl. //' �a'"'° '���
Filirg Dates: 1J Real Property: Dunng the AveNe (72) montbs belore Decem6er 37 o7fhe ysar fAe deducfion is fo��RSgGirye.�U�,!1� V A ��T`��
UI`+ �
2) Mo6ile Hwnes assessed urMer IC 6-7. 7-7 or manulacturetl homes nof assessed as real property`[JQnng fFie twehre (72J months
be(ore Ma�ch 37 olthe yeai the deduclion is to 6e eHective.
See reverse side Iw aaddional inswdions and quelificatlons.
Typa of 6enefit reaue5led (p/oaso Mack atl that appfj�
�er 65 Deduction from Assessed ValuaGon ver 65 Circuit Breaker Credit
Name N ao�m (ownar or cartmcl ovyo�
� �� �
Is appliwrit lhe mia legal or aQUitabla owneR It No, what is hislner exatl snare or �.t res17 If ned with mmeor.e other ihan soouse.
in iLatawil�whom
❑ Yes ❑ No
It name on recwd is diflarent than thal of a�oGCant itWicata belaw
Name o1 cont sailer (appNCant musf have been buying rn canUZCt at Masf ono (t) yea�
` PdCress of tl seller (numbw and sSee4 �: stato, a� ZIP wde) �s ihe pmoerty in cuesiion:
� Real property ❑ Mobile homa (IC 6-14-�
In disintl Key number / Lagal deunption Record number Page r.umbe:
a 6-P� - -c� l. 3�8 �a�
Is the propeM useC and occupiae pnmany kr Assessed value of the �ropehy as o( March 1, curtent year (may nof axcaed Sf82,d30
his/ner residenoT (or Orer 65 dotludim, w 5:60.000 !or Iho Ovor 65 Ci�cuit Breakar Crodit)
❑ Yes ❑ No
Was lhe app6cam 65 yeara of age a mora on December 31 d the year
Heve you filed for any oiher dedunionsl If Yes. wnat deductions?
p-� O No
Hava you filed (w deEuctions in any dher murtry? If Ves, wnat wunry?
� Yes No
I/VJe certify under penalty of perjury lhat lhe above and foregoing informa�ion is true and correcl and lhat the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20
SgnaNre of a� m q P.ccrass ot a�olimnt (r.umberantl slmef. ciy. s:a:e. antl ZIP code)
//
` �/C 1 ?� 3 i� S �1��G i,r��� o�� /�
Sig� rB of auL".odze0 re0resantalive Pddress of aW�orizec re�resentative (num0cr and s:met. city, stale. and ZIP cotle)