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APPLICATION FOR SENIOR CITIZEN
,. —rt. ? PROPERTY TAX BENEFITS
Sbte Fartn 437081R9 / 9-08)
` i�i � Ptascnbed by Me Department of Local Govemmeni Finarice
COUNTY
��y_�:a
� �� File Mark
Infortnatiom m�tained fn this document Is CONFIDENTIAL pursuant to IC 6-1.1-12-9 antl IC 61.1-35-9. �
INSTRUCTIONS: �
To 6e filed ln person or by mail with the CourrtyAudifw o/ the �unty where fAe property is locafed. /�T
Filirig Dates: 7) Real P�operty: Dunrg the tweNe (72) mwrths 6efrne Decem6er 31 of the year the deduction i�bHe e8e !'I'.�
2) Mobde Homes assessed uMer IC S 7. 7-7 or manu/actured homes rrot assessed as real pro�' Dunrn��_hY� (72J montirs
before March 31 0( Ne year the ded�ction is to be eHecfive. �
See ieverse side 7a add'aiona� instiuctions errd qua66cadrns. OIBgnN /p ��
f��Y'
�TYpa W banaN raQUested,�plmse Meck e0lhat ePWY1 / 2�G�Y d..'
Name
65 Deduclion from Assessed ValuaGon
w canlscf Duye�
It No, what is h¢Rier ezact s;ara w interesf?
�y i Yes ❑ No I
]T
name on reco(d is diRererit than that d eppGmnt, indicete below
Name d mrtrza se0er (applrcanf mus( hnw Dean
mntraC
ciry. sbfe, eM ZIP cn0e)
Key number / Legal tlescnpiion
Is �he ptopeM used and oavpied pnmariy br
his/har ras'WenmT
❑ Yes ❑ No
V7as tha aOW� 65 yaars of ege or mae on December 31 d ihe year
orior ta the wrtent yeaR
❑ Yes ❑ No
Adjusted gross income of appliwnt, spouse, and any
individuals sharing ownership (For Over 65 deduction, income
may not exceed 525, 000; for the Over 65 Circuit Breaker Credit,
income may rrot exceed 530,000 for individuals, or 540,000 fw
mamed couples).
Mava you (led fw ary dher deEuctions7
� Y85
Mava you filed lor deductions in eny mher counryT
� Yes
� No
� No
65 Circuit Breaker Credii
It owned with someone oiher ihan soa:se.
indimfe witA wtwm
pmverry in Quaslan:
�Real property � Mobile home QC 614-�
���
�Rernrd numbar Paae number
Assessed value of Ihe pmperry as ot March 1, current year (may rrof exceed
/or Over 65 Cedueion. ar 5760.000 /or No Ovor 65 Circuit &eaker Getli�
Applimnl's date W biR� (manN, day, yoa� If filed b
what w:
ot deaU
Source of Income
(S
IS
TOTAL I S
if Ves, what deduUions?
If Yes, what covnry?
surv'rving, un':rerried spousa,
ie spouse's age at lhe time
of Income
� �'�
I/We certi(y under penalty of perjury lhat the above and (oregoing informalion is true and correct and thal the applicant was a resident
of Indiana and owner of the aforementioned proparty on March 7, 20 _
SignffiureNaod'�M Pddressotaoou�m (m.mbere�sboo4ciry,state,aMZ/Pwde)
d auNw¢ed rapresantawe
reprasenialive (numDer anE 5✓001. ciry, stato, and LP cod¢)