Age_Byrne�
.,
APPLICATION FOR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
� ` � '! Stab Fam 43708 (R9 / 44B)
Prescnbad by the Depanmanl of Local Govemmem Financa
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COUNTY TOWNSHIP� YEAR
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File Mark
In(wmation oonUineC in Nis tlocvment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. AUIj 2 5 2��9
INS7RUCTiONS: •
To be filetl in persm or by mail with the CountyAutlitor o! the wunty where the property is loca[ed. �a� �
Filing Dates: i) Real Property: Dunng tAe fwefve (12) martlts beloie Decem6er 31 o7fhe ysar fhe d� �uction �s tdbIo1,�� .e,�� )
2) Mobile Hpnes assessed undei IC 67.1-7 0� manulactured homes rro( esseued a57ffHr�property Dtrn e t�i% (72 months
6e/ae Marrh 31 o/Ne year the deduction is to 6e eflecfive.
See reverse side 7a a0tlifional insWCtions arrd pualiRcations.
Type af baneEl �ue5ed (pleaso Uxk a0 fhat appl�
❑ Over 65 Deduction from Asseued Valuation
Nama pf apdKenl(owner or cu'rt+ecf DuyeQ /J
%, e� /� !w^"�.�w—� �
Ye (7 �'t��
iI
Is IimM lhe ede lepal or eQUitaWa wmaR If No, what
❑ Yes ❑ No
If neme on rewrd'u diffarem Nan
ezaccsnare w
ot mitred saller (epp"rcan� musf hare Oeon Duyinp on cmtract at leasf orro (i) yoarj
lddrass of mntrad seCer (num0orarN sboe( crly, sfalo,
L_ �.��
eM occupiad primanly br
�{ Over 65 Circuit Breaker Credif
i�
Key number I Legal tlescripiion
�/a-/a_o7-�0� -0oa.3
� Yes ❑ No
65 yeers ot ape a mora on Decambar 31 of t�e year
yeaR
� Yes ❑ No
Adjusted gross income of appliwnt, spouse, and any
individuals sharing ownership (FOrOver 65 deduction, income
mey not exceed 525.000; /or the Over 65 Circuit Breaker Credif,
income may rrot exceed 530,000 tor individuals, or 540, 000 for
mamed couples).
Have you filed M erry Wher deductions?
�s � No
tv tlaductiona in any olher cw�rty7
� Yes ❑ No
H owned with sareme dher than
intlimtavnthwhom /
Is t�e pro rty in puesiion
�Real property
'f-�
Reco�d numbar
�„3- o a 7?
�
home (IC &14-n
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�r
/
Ass¢ssed value o(ihe WaDerry as af March 1, wrtenl year (may nw' excead 5182,430
!or O�er 65 dedudiai, a f 760.000 /or Ne Oue� 65 Cuc�if Biezke� C�edi�
1lN/e certify under penalty of perjury that lhe above and foregoing information�is true and correct and lhat the appiicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _-
of appliteM ldEfa99 of applifan� (numborend s6eef, ciry, Stale, a�d ZIP coEO)
���r� a�3 �, Pi n e S(
aufher'rz��ya��ayC% � Address of euUmrized represan4tive (number and s✓ect ciry, sfate. and LPcrotle)
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