HomeMy WebLinkAboutAge_ReavisAPPLICATION FOR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
e� Sfate Fortn 43708 (R9 / 40B)
� Prescnbed by the Departmerit of Local GovemmeM Finance
G�
IMwmatbn oontainetl In this Eodiment is CONFIDENTIAL pursuant to IC 6-1.7-12-9 and IC 61.1-35-9.
COUNTY TOWNSHIP YEAR
�
File Mark
JUN 9 [.0 ��
INSTRUCTIONS:
To be Filed !n persm or by mail wifh fhe CountyAuditw ol the county where fhe properly is loca(ed. �
Filing Dafes: 7) Reel Prope/fy: Dunrg Ihe fwefve (12J mmths befae Decem6ei 37 0/ the ysar the deduction is to be e ct . ,,p �p�6p
2J Mo6ile Homes assessed uMer IC &1. 7-7 or manWacfured homes rrot assessed as real property: �I�(ty�p4i�1 q onths
be/ae March 37 o/fhe }rear the deduction is fo 6e eHective. G��
See reverse side lar edddionel insWCfions arM qualificetims.
TYpe of benefit repueited (pleese d+eck a6 Nef apply)
❑ Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit �
Name of a0��m (ownx ar convacf ovyeQ
� � o
/C'�c�� � F
�
� aOD�itl e mle lepal or aQUitaWa owne(7 If No, what ia hisfner exad share or inte�est7 If owned with someme other ihan spouse.
iMitate whh whom
❑ Yes ❑ No
If nama on record is diflereM Man Nal d applifant indiceta below
Name d controct seller (appllcanf musf hare bean buying on cmtrdc+ at leasf orre (i) yearj
Pddress W mntred sePer (m�mbei aM atreaG ciry, sbfe, end LP mde) b the pro erty in Quesiion:
Real pmperty � Mobile home (lC 6-14-�
� Taxi� ' irid Key num6er I Legal descnption Record number Page numeer
�-�.� 3S- �lo-a�.�o -G�
Is �he o�DeM1y ased and acwDiad pnma for I Assessed valua of the pioDeM as of March 1, cuRem year (may not exceed 5 f B2,d30
his/her residencel for Orer 65 deductim, a 5160.000 /oi Ne Ove� 65 Ciicvt &eaker CredrQ
� Yes ❑ No
Was the ao0��m 65 yean of age w mwe on Oecember 37 of ihe year A o��nfs da�e of bitlh (monM, tlay, yoar) If �IeO by a surviving, unmamed spouse,
orror to the artartl yea�7 �
Inwme Amount of income �
individuals sharing ownership (ForOver 65 deduction, income I S
may not exceed 525,000; (or the Over 65 Circuit Breaker Credit,
income may rmt exceed 530,000 for individuals, o� 540,000 for I g
married couples).
TOTAL S 0.00 I
Have you fled tor aery olher dad�cGOns7 �f `/es. what deductions?
� Yes ❑ No
Have yo� fJad tw deductions in any aher counryl ( If �bs, whal counry?
� Yes ❑ No
IIVJe certify �nder penalty of perjury that tha above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ -
�Signaturada faM MO�essolapplimr.i(numbaarMStreaf,ciry,sWfe.a�MZlPCOde)
Y` /�/ S�G' ��t -�,✓ 7G �a
� Signriure ot auLhonzed'enrese aCve Ad 'ess af aNtrorized reDresentative (num6erarM sueef, pry, state, and LP e)