HomeMy WebLinkAboutAge_Kirkx,�"' a APPLICATION FOR SENIOR CITIZEN couNn � TOWNSHIG � YEAR
_ . PROPERTY TAX BENEFITS
� ' State Fortn 63)OB (R919-OB)
Prescnbed by Iha De�aM1ment of Local Govemment Finance
Information wntained in this tlowment is CONFIDENTIAL pursuant fo IC 6-7.1-12-9 and IC 6-7.135-9.� ���il�
INSTRUCTIONS:
To be filed in person or by mail with !he CouMyAuditor o7 fhe counry whera the properry is located II ( p 9�
Filiry Detes: i) Real Property: Dunng fhe tweNe (72) martAS befae December 37 0/ fhe year fhe deducfio��Tbb�6Nctiv�o�
2) Mobile Hanes essessed u�Mer IC 6-1J-7 or manNactured homes nof assessed as real pmperly: Dunnq flie Mrehre (72) mrntbs
belore Mardr 31 0/ the year fhe deduc6on is fo be eflective. �a J���
See ieverse sitle tw additional instrucfions arM qualificafions. _ _,_� �
repuesied (ploa5o tlixk a0 Maf aOPM
�Over 65 Deduclion from Assessed Valuation
Name d epd�cant
la applipnt tha sda
tntract DuyeQ
l'„ ' ' ..�J ���
�'� Yes ❑ No
name on fewrtl is diRarem Ihan that of aod�cant iMicate
Neme at
conaaa
I/ No, what is hislnar ezact share or
been buyirg m cont2ct af least orm (i) yca�
(numDCr aM sbcet, ciy. sta.o. aM ZIP cotle)
Key number / legal tlescdpiion
Is ihe propeM1y useC and occupied D�marily br
nismer residence?
� Yes ❑ No
Waa tha eoW��165 years of age or more on December 31 of tne year
DnO� IO Uie air�aM yea(!
� Yes ❑ No
Adjusted gross ineome of appliwnf, spouse, and any
individuals sharing ownership (For Over 65 deduction, income
may nof ezceed 525,000; (or the Over 65 Circuit Breaker Credif,
income may irot exceed 530,000 (or individuals, or 540,000 for
married couples).
Have you filaE for any olher deEuUions?
QYes
Have you 61eC for deEUCtio�s in any other cwnry?
❑ Yes
Over 65 Circuit Breaker Credit
If owned with someone o�her than spouse,
indip�e with whom
Is tne omoerty in ouestion:
� Real pwpery � Mobile home (IC 644-7)
Record num5ar I Page r.umx:
Assessed value o( the �moerty as of March 1, wnert yaar (may not ercee� 5�92.d30
for Owr 65 tloduUion, w 5160.000 br Iho Ove/ 65 Cimuit Braaker CreCi�
A�ptimnfs dale of bitlF (month, day, yoar) If filec hy a surviving. w.Tamec spouse,
wnat was ihe soouse's apa at the time
of ceatn?
If Yes. wnal ceducY.�
� No �
If:es,wnatcounty4
No
Income � Amount of Income
TOTAL � S 0.00
I/VJe certify under penalty of perjury that the above and foregoing information is true and correct and lhat the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1. 20
� SpnaNraolapd���
Y?��/,v�,a
Address of ao0��mr.t (numGCr ar.tl sUCeq ci:� s: . antl ZIP cotl�)
��o� �lc�, ,� ��c� � �7� � �
PAdress ot authodzed r�Trasantaliva (nvmbcranL sbool. ci.y, sta:e, antl Z/P codo)