Age_Hanoldm
APPLICATION FOR SENIOR CITIZEN C�
. PROPERTY TAX BENEFITS
S ' Smte Fortn 437081� I 908)
� P�ascnbed by �he DepartmeM of Local Goremmerit Finance
Infomiation wntained in this doaiment is CONFIDENTIAL pursuant to IC G1.1-12-9 and IC 61.135�9.
INSTRUCTIONS:
To be filed !n person or by mail with the CountyAUdita o/ fhe counry whera fhe property is locatetl. P� ���U �(J
Filirg Dates: 7) Real Property: Dunrg the fweNe (72) mmths 6e/ore Decem6er 37 of the year the deduction is to e effecfnre.
2) MobNe Homes assessetl uMer IC fri.1-7 or manu/BCtureO hanes rrot assessed as leel properly: e Mm (72J mmths
��
6e%re Marct+ 37 0/ Ne r Ne deduction is to be eBecUve. � 419
See reverse side fa addifional inswctions � qualifications. � sON Cp N��. A N���._
TYGa of Ee�refit ta4uesteE (Wease d�eck aH Nat a0W)'! ,
❑ Over 65 Deduction hom Assessed Valuation � Ove� 65 Circuit Breaker Credit
/ �
Name of apWitaM (owrre� a cmGacf Guye�
� �a.�. �I � al�P
,
b epplim Na sde lega epuitaWe vwne(/ tl No, vAwl ia hia/her exad shara w interest7 If owned with someone Wher than 50wsa.
indicate wilh whom
❑ Yes ❑ No
a name on recad'u aMerem uian mat a eoMxa�t ��d'Kate be�v«
Name m comraa seuer (eppPcsnt mvst nnve seen euy'ug m cmliaa at leest orre (f) yaeq
seller (numAei aM s6aeG ciy, sfa�, aM ZIP code)
� Tazine disinq
(.�
U iha 7�PeM used aM occupieO MmariN
hiWher reaidencs7
� Yes ❑ No
Was tha applNaM 65 yean ot aga or rtrore on Decamber 31 of 1t+e year
pAar to Ne arter� yea(!
❑ Yes ❑ No
Adjusted groas income of applicanR $Pouse, and any
individuals sharing ownership (ForOver 65 deduction, income
may not exceed 525, 000; for the Owr 65 Circuit Breaker Credif,
income may rwt exceed 530, OOO )or individuals, or 540, 000 (or
mamed couples).
Fiave you (Jed 1or arry othar detlw.tions?
� YeS
Have you filed for deductions in any other cwrity?
❑ Yes
� No
� No
� Real pmperty � MoDile home QC 6-14-�
Record number Page number
�a- auo. a�r-�oa� I
l�sesseE value of Ihe propefty as ot Maich 1, wrten� year (may rn
fo� 0`er 65 Ootlueim, m 5760,000/or Ne Ovor 65 Circurt &eakai
Inwme
deductions?
If 1bs, what wunry7
tl filed by a suniving, un:remad soousa.
whal was the spousa's age at lhe �ime
of deam?
Amount of Income
S
S
TOTAL I $ 0.00
I/We certify under penalty of perjury that lhe above and foregoing information is true and cortect and that the applicanl was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20 _
7neture of aoprxun // Addreas of epv���� (��ber aM sboe4 �M. �re, and ZIP catle) '
Signalure af authorizetl �eD�asertlaWe I MOre59 of eWhwized reDr8s9nietive (numbar aM aboaf, city,