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APPLICATION FOR SENIOR CITIZEN �
PROPERTY TAX BENEFITS �
� �--. �' StatBFOrtn63708(R9l9-08)
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Prascnbed by Ihe Depariment of Local Govemmem Financa
COUNTY I TOWNSHIP I YEAR
Y EM8 K
Informatbm m�;ained in this tloament is CONFIOENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9- �
INSTRUC710N5: � �
To be file0 in persm o� by mail wflh the CounryAUditw o/ the counry where the property is located. OGa
Filing Dates: 7) Real PropeRy: Dunrn,7 the tweNe (12J mrnths befae Decem6er 37 0/ the year the uction is f� 6�e�
2) Mobde Hanes essessed untler IC 6-1J-7 or manWactured hdnes not essessed as real prop� unrn� Ne fweNe (12J months
6efwe March 37 olNe ear the deductlon is to be effective.
See reverse sitle fw additional instnictions � qualiAcations. � � V1Z0�
Type W Denefit (ep��°"^A Weaso chxk aD fhaf appty) ON C�
BS
Over 65 Deduction 6om Assessed Valuation - Over 65 Ci�cuit BrE'�ker Credit
eoo�m �oar�er o. cannac� euyo� �
�.//���� f
If No, what is
Yes ❑ No I
name on reco�d is diffe:ent �han thal af eodicant, inEicate
�i�%.
Name d mrrtad saller (apdicanf matl /iaro Dean �vyiig on cm✓acl at basf orro (�) yea�
AdEress d cantratl seller (number eM sboet try, sfafe, aM Z/P code)
,/o?��-%Q3-�O/.
Is Ne wooaM used and occupied onmany br
hisllierres�danw7
Yes ❑ No
VJas ihe a�Wi�aM 65 years of aga or more on Decemb 31 01 the year
D�iorto Ne aireant yaaR
Yes ❑ No
Adjusted gross income of appliwnf, spouse, and any
individuals sharing ownership (FOrOvei 65 deduction, inoome
may no( exceed 325,000; lor the Over 65 Circuit Breaker Credit,
income may nof exceed 530,000 for individuals, oi 540,000 fo�
mairied couples).
Have yau lded tor any Whar Eeductions7
'h(1 Yes
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Hava you filad for deCUCtions in any oIDer cwnry?
� Yes
� No
No
II owned vrith wmeone other ihan spouse,
indimle wi�n wnom
ihe �moe�ty
Real property ❑ Mobile home QC 644-�
rcordrumber Page numcer
0.ssassed value of the orooerty as al March 7, wrtent year (may nof arcoeG 5182.<30
for O�er 65 doduaion, or 5160.000 hr tha Ovoi 65 Circui: &eaker CroEi�
� '.'..
IfYes.wFatdeEucHons?
�/-S• � � l�
tl Yes, x:�al wuniy?
7�—
INJe certify under penalty of perjury that the above and foregoing information is We and correcl and that the applicant was a
o( Indiana and owner of fhe aforementioned property on March 1, 20 �
anature a�W'¢xr.t Address ot ao0lirar.t umEerantl s et, ci,y. s:aio, and ZIP codo)
� ��
gn ra N authorized reorese tative Addrass of�ut`oraed reoresenWtive ( umberarN s.reet, ciry, sfate. and ZlPcode)
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