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� "' APPLICATION FOR SENIOR CITIZEN �
� PROPERTYTAXBENEFITS ��
(ti ... -'. Spm Fortn a3]081R914O8)
� Prascnbed by tha Departmem ol Local Govemmem Firanca
IMormation contained in this tlowment is CONFIDENTIAL pursuant to IC 6-1 J-1 &9 antl IC 6-1.135-9.
INSTRUCTIONS:
To 6e �led in persm or by mail wdh the CountyAudita o/ the county wM1ere Ne property is located.
Filily Dates: 1) Real Property: Ounng the MreNe (72) months belore December 37 o/fhe yearihe�
2) Mo6ile Homes assessed under IC 6J.1-7 ormanulacfuretl homes�� a� sed es real
belwe Marrh 37 07 the year the deduction is to be e� �
See reverse side lor adtlitional instrudions end quafifications.
/.r
Type d 6eneH reuuastetl oese rhecke➢Iliat epply)
�
COUNTY
/ File Mark V.
�► �,�'�.
be e//ective. �
Dunrrg the tweNe (7 months �
❑ No I
on �acorO is diRerent Ihan tha� of a0d�nt indicate bebw
Name ol coMrzct SeAer (appicant n, ust haro Eeon buyirg m cronuac! at loasf orro (1J yca�
Addrass d mntrad seller (numbor aM s4cot ury, sfate, aM ZIP cotle)
I Legal deu�/notion
/o� OJ G i
Is Na o�oeM used and occuDieE o�rt+any br
hisRiarrasidenw7 ��-�{
`� Yes ❑ No
/�
Was the eoo��n165 yean of ege or mwa on Decamber 31 W Ihe year
D�r to Ne wrrent yea(7
� Yes ❑ No
Adjusted gross income of appliwnR spouse, and any
individuals sharing ownership (FOrOver 65 deduction, income
may not exceed 525,000; for lhe Over 65 Circuit 82ake� Credif,
incane may �rot exceed 530,000 for ind'rviduals, or 540,000 for
married couples).
Hava you flad for any olher deducirons7
� Yes
Hava you filed for deducUOns in any aher wuniy7
� Yes
� No
� No
If ownad with
inditate wi�h
�y
Is the o�ooerty in auestion:
spouse.
Real propery � Mobile home QC 644-�
•��'/(/�� /R7ecord n/Jumber Page r.u:nber
O ��/��)
property as of Ma¢h 1, mrtect year (may rwt exxrtl 5�82.a30
or 5 f 60.000 fur tho Oval 65 Cir�ir. &caker Cmtli;)
INJe certify under penalty ot perjury that the above and foregoing information is We and correct and lhal the applicant was a resident
of Indiana and owner of the aforementioned property on March 1. 20
JSignetureolapP���� E d�ssofeppli�rt (nvm0erantlsVCet,ci,y,staro,antl2lPcotle)
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_ . � o / ,C Gti4 �S O I,Jeh V ` J- �
� Sgnatweota ed�e0flantative Addrassofauthwizec:eo.asentatrve(numDOrands:ieel,cify,sfaro,andZlPCOOa)