HomeMy WebLinkAboutAge_Bedwell�"' APPLICATION FOR SENIOR CITIZEN
�;��..( ' PROPERTY TAX BENEFITS
'��,l• Sbb Fartn 43708 (R9 / &O8�
��� Presaibad by ihe Deoartment of Local Govemme:it Fir.ance
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Infwmatiom m�tainetl in this document is CONFIDENTIAL pursuant to IC 6-1.1-12�9 and IC 6-1.735-9.
COUNLI' TON(pIS�}IP YEAR
� ' �
DEC �''�l"�`tb8
/NSTRUCTIONS: `-�-,<'G /l .__
l/( N!_-�
To be filed in persm or 6y mad wdh fhe CountyAuGrta ol fhe county where fhe property is Ixafetl. �
FilirrgDefes: 1) ReelProperty:0unngtheAveNe(72)mmthsbe/oreDecember3lo/theyear(hedetl�ction�;gSaeHesfrve.�iTy p(�pITOP.
2) Mo6ile Homes assessed urMer IC 6-1. 7-7 or manu/actuied homes not assessed es real pmperty: Dunng the hveAre (72) months
6e/ore March 37 of Ihe year the deduclion is fo be eflective.
See reverse sitle tor atldifional insWClions and qualifications.
Type of benefil(epuesteE (p'aese check a0 thaf apply)
❑ Over 65 Deduction from Assessed Valuation �r 65 Circuit Breaker Credit
Name ot aoW�m (mmer a canfract EvyeQ
$ �--1(�1�.9 ��eQ�Q-
Is a001imm the sole leqal or apuitable R II No. whzt is nis/her ezad share o: inlerestt If owned vnin wmeone other than soouse.
i�ditate vnt� wnom
❑ Yes ❑ No
It name on record is diflarent t�an ihat oi aodiwn4 ��dicate bebw
Name of contrad sa0er (applicent m�sf haw Dean Ouyirg on cmuact at loasf orro (tf yea�
� Pdtlrass W mntrad sellar (number aM sbcol, cM• staro, antl Z/P code) �s �ie omoerty in Cuesiion:
� Real propery � Mobile �ome QC 6-7J-�
Taxing disin Key numoer / legal tlawd�tion I Record number Paga number
�� �cZ� � � �i-3�'OOD.�- 00 �
Is ihe pro0erty useC and occuOieE D�many br Assessad value of iFa omoerty as ot Ma¢h 1, cur.er.t year (may not excceE S;d2.a30
hisfier rasidenw7 `or O�ci 65 dcduGirn, w 5:60.000 lor Ne Over 65 Cirtuit Bmaker CmCi1)
❑ Yes ❑ Na
Was tha aoo�aM fi5 yean of aga w nwre on Decamber 31 0l ine year
olaeam?
Adjusted gross income of applicant, spouse, and any �
�s ❑ No � ��
Have you fJetl for daductions in any other counry7 If Yes, what wuniy?
❑ Yes ❑ No
I/We certify under penalty of perjury thaf the above and foregoing information is true and correct and thaf the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Sgnature of a0pfrarit Addrass ol aoD��� (�umDerantl stroof. ci.y. s;-;o. a ZIP rooe)
� � ��� 7,�2� s�000�o��c�r�� y�6��
Spnatura of authorizeE reoresentative Mtlress of authorizad reorase��tative (nvmbar antl s:roel, ciry, sfa:e, and ZIP code)