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APPLICATION FOR SENIOR CITIZEN
r ..-rt ? PROPERTY TAX BENEFITS
Sfata Form 43]08 (R9 / 9-08)
'�� Presaibad by Ihe Depa�lmeM of Laal Govemmem Finance
Informatiam m�Ginetl in Nis tloaiment is CONFIDENTULL pursuanl W IC G7.1-12-9 antl IC G1.135-9.
iNSrnucnoNS:
COUNTY TOWNSHIP YEAR
Fle Mark
JUN 3 0 2011
To be filed in person or 6y mail wifh the CountyAUdi[or ol the munty where the pioperty is locafed. �`.�j,
Filirg Dates: 7) Reel Property: Dunng Ne hveNe (12J mmfhs 6e/ore December 31 07 the year the detlucfion is lo be efleclive.
2J MobileHwnesassesseUurMerICG7.7-7ormanufacturedhanesirotassessetlasrealpr�yudicDunrp7lhUNTMA DITORS
be/ore Marctr 31 0l the year the deduction is to 6e e/fective. ��SJUfJ t;0
See �averse side Iol eddAional insLucfions and qualifications
Type d heneft �eque.s,i�ed,(lg'ease Mect a0 Naf app�j�
IXI Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
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NamedappGra ovm(varcmf�acfb Q
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I5 apP��M Ma sde lepal or equitaNe ownaR H No, what is hislher ezad share w inieresl? If owned with someone mhar lhan spaum,
inEirate with whom
❑ Yes ❑ No
It rama on �ecard is diflarertl than that ot apqirant ���e bebw
Nartre af cwrtrar] sa0ar (appl¢ant must have Daen b�ry'ug m canvad at loa9 one (7J yearj
Pddrass d mnbatl seller (numbeiaM sbee4 uN, sGk, and LP mCe) �s lhe p(opefty in Ouesiion:
Real properry � Mobile hwne (lC 61-1-n
Tazing �s G Kay number/ lagal dawipiion Rewrd number Page num6er
' -OQ . � ' Q
Is Iha pmpery usaE antl occupieE pimariy for I Assassed valua of Ne popefty as of March 1, curtant yaar (may rwt ar�aotl 5782,630
IusTher residanw7 fo� Oeei 65 dedurtis�, or 5160.000 for Ihe Ovar 65 Cirnit BiaalarGod�Q
❑ Yes ❑ No
Waz Ne appficarit 65 years of age or mwa on December 37 of tha yaar AppGmnfs date ot biM1h (monlh, day, year) I( fJaE Fry a surviving, unnerried spouse.
pnor to the wrtant yeaR what v.as the spouse's age at the lima
❑ Yes � No otdeam9
Adjusted gross income of appliwnt, spouse, and any Source of Inwme Artrount ot Income
individuals sharing ownership (For Over 65 deductiron, income $
may not exceed $25, 000; /or the Over 65 Circuif Breaker Credit,
income may not exceed 530, 0007or individuals, or 540, 000 for $
married couples).
TOTAL $ �.�
Have you ketl lor arry dher deductions7 It 1§s. whal dedudioivaT
� Yes ❑ No
Nava yo� filaa tor deducCOns In any aner ca,my7 u ws. wha� ca,my4
� Yes ❑ No
IlWe certify under penalty of perjury that the above and foregoing infortnation is true and cortect and lhat the applicanl was a residen[
of Indiana and owner of the aforementioned property on March 7, 20
Sig ure appficaril Address oF applimM (nunberand sWet, rify. sfate. aM LP wde) �`
� 3 S. t�l � • Kc��o.,� -+'K '� 7670
Si ature autha¢ed representaW; ^ Address of authwimd rapresentative (numbmaMSheef, cify, state, sn TJP cotle)
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