Age_Fauquher� APPLICATION FOR SENIOR CITIZEN (� � �nuNr,� ro asrpP rena i
.,. . : PROPERTY TAX BENEFITS 1` � � '�
� --', StafeFortna3708(R9/408) `�
P(es�bad by Uie DeoaNmeM of local Go�emmartl Finance ,�,/7,nf1
Infortnation wntainetl in this document is CONFIDENTIAL pursuant to IC 6-1.1-�2-9 and IC 6-1.135-9. DEC 1���"eW
INSTRUCT70NS: � ��
To 6e filed in person or by mail wrth fhe CountyAutlitor o7 the counry where the properry is locafed. ��G �
Filiry Dafes: 7J Real Property: Ounrg the tweNe (12) months be/ae December 31 of the year the deduction i���f�Q+Ql.I I�7Y AUDITOR
2) Mo6ile Hwnes assessed urMer IC 6-1J-7 ormanu7actured hwnes rrof assessed as real pmperty: Dunng fhe twehre (tt) monffis
before March 31 0l fhe year t6e detluction is to 6e e%ective.
See reverse siUe fa adtldiona/ instrudions erM pualifications.
Typa d beneft raouested (plaase tlieck a0 Nal appyj
� Over 65 Deduclion from Assessed Valuation �Over 65 Circuii Breaker Credit .
Name of epWiraM (vn+rer d cmtracf Ouyoh
�1 � •
Ls a�plimM lhe sde leyal or apuitaDle owna(7 If o, whn is :isL�ar exact scare or L^te:esi? If vxned wi�` someone ather than spouse,
I'IQIqIB N'��i1 WiAT
❑ Yes ❑ No
It name an record'u differem than ihat o( aodicar� irWicate bebw
Name ot cart2p seller (applicanf must haro Doan Ouyilg d: cmtract at leasf oiro (i) yea�
� MEress ot mr.tratl 5611Br (namDwaM s'veet. CrY. slalo, and ZIP todo) �s �ne omoerty in ouestion:
Real pmpery � Mobile home (IC 6-14-�
Tazin distnct _ I Key numbeN legal dascnotion I Record number Page r.umber
,26 -18-d1-.�Q� -DD�, a3�3 ;o�.�
Is Ute OroDaM1y uSBC and occuOiBE 0����' br 0.ssessed value of ine omoerty as o( March 1, cunenl year (may nol exceetl 51B2,e30
his/ner residenw7 :or Orer 65 dodudiw:. or 5160.000 !or tho Over 65 Gircui! &eakor Credi:)
�Yes ❑ No
Was the aoPlicaM 65 years of ege w mwe on Oacember 31 ot the year
Have you filed for eny othar detluctior:si If Yes, wnat deduc6or,s?
Yes ❑ No `� S
Have you fJed fw deductions in any other wunryP If Yus, what counry?
� Yes ❑ No
INVe certify under penalty of perjury lhal the 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
Sgnature of apdKert AaEress of aoo��car.i (number and sUOet. ci,y. ifato. antl ZIP wtlej
., � D S� -S' - �/S�� '�/% � �
Sgnature of auLhonzec reDresentative AdCress oi authorizeC reoaseNalive (num5orontl s✓eet. ciry, sa:e, and P code)