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APPLICATION FOR SENIOR CITIZEN
- . PROPERTY TAX BENEFITS
S--, Sbte Fam 43708 (R9 / 9-08)
Prascnbed by the Department of Laral Govemmem Finance
C�
Infwmatam m�talnetl in Nis tloament is CONFIDENTIAL pursuant to IC &1.1-12-9 and IC 61.7-35-9.
COUNTY TOWNSHIP � YEAR j
�� ���
INSTRUCTIONS:
To be file0ln person or by mail with fhe CountyAuddw o/ fhe aounty where the property is locafed. 1
Fili�q Dalas: 7) Reel Property: Dunng fhe hveNa (12) morrfhs 6e/ore December 37 0/ the year the deduction is to b9 �d�cti�. 3 2�� 9
2) Mobile Hames essessed uiMer IC 67.7-7 o�manufectured homes rrot assessed as real property: Dunig the fweNe (12) monms
before Marci� 37 0l the yeer fhe deduction is to be eRective. `�y��� ii /%.
See reverse sfde /a adtldional insLUCtions eM qualificatims. �/'t N�+�•�.
U
❑ Over 65 Deduction from Assessed Valuafion
Name d ap06caM (awrrer
b
EvyerJ
It No.—what ig
/ Yes ❑ No
name on remrd ia difteraril ihan thnt af epp&anl iMicate bebw
Name of comaU feAer (eppytanf mus( hare baon
Y��
Over 65 Circuit Breaker Credil
or imarest7
� Pdaress W wntra / �(n� M abaet cit�: sdle. arW ZIP code) Is tt
T�ing distri Key number I Leqal descnplion
o�- f�/l.Ovt-e.� o� �-1 2'-�3-�k3�m. OlA3-o�v
U Ne o�DaM useO and occuDietl pnmany br
�i151)IBf 1B51dB(IC67
Yes ❑ No
i5 years of age w rtwre on Decamber 37 W the year
yeaR
Yes ❑ No
Adjusted gross ineome of appliwnR $Pouse, and any
individuals sAaring ownership (FOrOver 65 deduction, income
may not exceed 525, 000; for the Over 65 Ciicuif Breaker Credit,
income may rrot exceed 530, 000 for individuals, or 540, 000 for
mamed couples).
Mava you filed for arry other deEucfions9
❑ Yes
Hava you filad M deducfmns in any alher courrty?
� YBS
N owned vnlh someone other Ihan spouse.
indipte with whom
D�DeRy
� Real property � Mobile home (IC 6-74-�
Record number � Paae r.umber
AssesseC value o! tha pmPerty as of March 1, current year (may lwf ercectl StHZ.a30
!or Oeer 65 dodueion. ar S 160.000 Ior Ne Ovar 65 Cticurt &oaker Gedin
Mo��nfs date of binn (man:A, tlay. yea� If filec by a surviving, unmartied s�ouse,
whai was tha spouse'S aga a� the Cune
ot deaN?
� �
Amount ot Income
�.� /Ce.1��. I S a �s a�.
S
I( Yus, what deductions?
No
Ir 1§s. what wuM`i?
�v� "v
TOTAL � S 0.00
IIWe certity under penalty of perjury that the above and foregoing information is We and covect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
SignetureofappGCerM1 AddrasaofaPP�m (numbarendstreet,tiry,stafe.aIMZIPcode)
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Si�1natu(e Mauthonzed rap(esentative Pddrass of aWhodzad reo�esaniative (number aM sveeq city, stafo, antl LPcode)
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