Age_Johnson (2)• APPLICATION FOR SENIOR CITIZEN \ J-�
;..rt PROPERTYTAXBENEFITS �\ J
� State Frnm 43708 (R9/40B) �
�� � Pr¢yai6ed by �he Depanmenl ol Local Govemment Financa
information oontained in Ihis documen; is CONFIDENTIAL pursuant to IC 6-7.1-�2-9 antl IC 6-7.1-35-9.
�
l�J
COUNTY TOWNSHIP ( YEAR
1
A 1S—J -
�t�"� �� %ous
INSTRUCTIONS: .
To 6e filed in persm or 6y mail wRh the CountyAudita o/ the wunty where the properfy is loca(ed. ��64 �-� �
Filing Dafes: 1) Real Property.' Dunm� fhe tweNe (12) months belwe Decem6er 37 of the ysar the deduction is fG�gN,gNctivg�_.�j�,ITY AUDITOR
2J Mo6ile Homes assessed under IC 6-1.7-7 ormanulacfured homes rro( assessed as real pmperty: n pg\ the tweNe (12) montlis
before March 31 07 the year the deduc6on is to be e/lective. ,� �^ \\ ^�
See reverse sitle (or addtional insWW'ons eM qua/ificatlms. 1
Type d beneFt repuesce0 (ploaso
Name at epoGCarM1 (�
Is aDO��m the ede
If nama on racaN is
Over 65 Deduction 6om Assessed Valuation �Over 65 Cirwil Breaker Credit
r contract buyoQ
' L
r epada0ta wme// If No, what is hislnar ezact share or interest? If axned with wmeone olner than spoase,
indiate wit� whom
es ❑ No
n Nan thal ot appifrant indiwte below
Name of mmrad seller (app/kanl must haw
Addrass ot wntratl
m cmuaU at bast orw (1) yca�
r�ry, stafe. aM ZIP cotlo)
Tazing disL•ict Key numCer / Legal Eav
� ��P R, �-l1^Q3
Is Ihe pmoeM useE and accuoieE D�manty far
hisrtierrasidence7
� Yes ❑ No
Waa iha aod�cam 65 years of age or more on December 31 of iha year
pnor to the wrtem yoaR y�
ff'1 Yes ❑ No
T
Adjusted gross ineome of appliwnt, spouse, and any
individuats sharing ownership (Fo�Over 65 deduction, income
may nof exceed 525,000; !or tAe Over 65 Circuit Breaker Credif,
income may rrof exceed 530,000 for individuals, or 540,000 !or
married couples).
you filed for ar,y aher deductior.s?
� No
Hava you fded tw Eaductions in any other counryl
� YES
I Is Ibe orooerty in cuestion:
�teal properry ❑ Mo6ile home (/C 6-7J-�
n�tirn I Record number Page numeer
-`t�-�3�3y-aa-�
Assessed valua ol ihe arooerty as of March 1, wr.ert year (may nol ercECd S1B2,d30
:�rOror 65 Eodudion, or 5160.000IOrtho Ovcr 65 Cirtuit &oakor Credit)
I Aa�li�anfs
_�� �� �na,,.
Source oi lncome �
IS
IS
TOTAL I S
It Ves. w"at aeductior.s?
Ir Ws. wnal counry?
Amount of Income
� ��
I/We certify under penalty of perjury that the above and foregoing information is true and correcl and thai the applicant was a resident�
of Indiana and owner of lhe a(orementioned property on March 7, 20 _
gnatu'a d appficaM <dLress of aoo��r.t (numDeiantl sWet, ciry. staro. aM ZIP cotle)
'� �o �,°��O.�v 1� 3� o� E��� N�/'yc�v �`� 7� 7d
3hatureotauMwizedreore ntaWe dressofautnwizadrea�eser.tative (nomSeraiMS:ieel.ciry,slato,ar.dZlPCode)