Age_Pendleton�
"' �. APPLICATION FOR SENIOR CITIZEN �
� PROPERTY TAX BENEFITS �
� .._�'• SlateForma37081R919-OB)
� Preauibed hy Ma Departmer� of Local Govemmem Finaxe
Informatbm m�iainetl in this Cocument is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC &7J35-9.
;K�PI:1�1
� �
TOWNSHIP I YEAR
INSTRUCTIONS:
To be filetl in person oi by mail wrth Ute GountyAuditor o/Ihe county where the property is locafed. ��n �� �ooft
Filing Datas: 1) Real Property: Dunrg the AveNe (12) mrnths be(ae Decem6er 37 0/ the year the deduction is t �//e �
2J MobNe Homes assessed under IC 6-7. 7-7 or manufactured homes rrof asseued as real property� Dunlg the hveAre (72J months
be%re Marct+ 37 0/ fhe ar Ne deduction is to be eflective. p./�/ ��/s�q/
See ieverse sMe !or aOtlifional insWCtions a 9�lificetions. �` � q pITOR
TYGa d beneft �eauested (P�ease Meck a9 Nat appl�
❑ Over 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credit
Name�W�m �o»,� a ca,r,��� e�ye,�
� � �
b aov��m �he lepal oreduitable wme(1 tl No, w1w1 u hisiher ezaO share or irtlerast7 H owned with someone Nhat than spouse,
� ' indicatewithwhom
❑ Yes ❑ No
H name on retad b Oifterairi Ihan tlut d appfivnt indiwia belax
� _ ��
� Name of conUaa aener (epdicant must have Deon buyirg m convact at least or�e (t) yea�
C
�
Address ol mntratl aeller (numbm arM sbeet
t'� r� ab -
Is �he propeM used eM occupeE pnmariy br
higfier res'dencs9
❑ Yes ❑ No
Key number I legal desuiplion
.„L.,.
Was �ha aOD�� 65 yeara ot age w more on December 31 of tne year
D�O�lO MB QIRBM YBBYI
� Yes ❑ No
Adjusted groas ineome of appliwnt, spouse, and any
individuala aharing ownership (For Ove� 65 deduction, income
may not exceed 525.000; for the Over 65 Circuif Breaker Credit,
income may rrot exceed %30,0007or individuals, or 540,000 (or
mamed couples).
Have you filaC for
Hava you fJeE M
airy Wher deductions7
� Y65
any dher coumy?
� Y85
� No
� No
Is ine pmperry in duestbn:
� Real properry � MoDile hwna (IC 6-14-�
Ramre number Paae rumber
,,.,� , ��.,� �
AssesseO wlue of 1he pmpefty as of Ma¢h 1, wrtent year (mayrrot ercoetl5182.a30
(orOror 65 tletl�eian, w 5760,000 hr (ho Owr 65 Cucluf &aakar CroOi�
��
-��
� . �.
IIWe certify under penalty of perjury that the above and foregoing information is true and cortect and that the applicant was a resident
of Indiana and ow er of the aforementioned property on March 1, 20 _
Signeture ol e Pddrass of ap0licent (nambor and sbael. ciry, sfato, aM Z/Pmtlo��
3 S 4DE
Sia :a of euNOnzeO reoraseritative Adtlrass of aultqrized representative (numberarid sboel. ciry, sfato. an0 ZIP coCe)