Age_Beauchamp�
APPLICATION FOR SENIOR CITIZEN
- . PROPERTY TAX BENEFITS
y i� Stale Farm 43]08 (R9 / 9-08)
Presaibed by ttia Dapanmam of Loral Govemmeen Financs
Infwmatiom m�tained in lhis doamenl is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC G7.1-35-9.
COUNTY TOWNSHIP YEAR
INSTRUCTIONS: � � �� �
To 6e filetl in person or by mail with the CountyAuditw o/ the county whe�a fhe property is located. � I��O ��
Filirtt) Dates: i) Reel Property: Dunng Ihe lwelve (72J mmths belwe Decem6er 37 0! fhe year fhe deducUar is to 6e e
2J Mobile Homes assessed under IC 67.1-7 or manu/actured fiomes rrof assessed as rsel pioperly.' Dunrqfh� hveha 72 mmfhs
be/rne Marrh 31 of the year the deduction is lo be eflective. `
See reverse side fcr adtlitional insVUdions and qualificatims
Type of beneft repuesfed (piease Matic all fhat apply) ,
Name of
n �ma on rac«d is
Over 65 Deduction from Assessed Valuation
or cmUacf euyed
or aquitaNa wmen
❑ Yes ❑ No
Nartre o( mrt(ad seAer (appl�canf must hare been
AdCrass d wntraC sellar (number aM sbeef. �ly, sfate.
m contrad af kasf one (1)Y�d
uN LP code)
Kay number / legal Cewipiiw
-�_ �3-�/ .
I5 �he O�oPeM used ard oavpied P��N br
hisTherresiEenm?
❑ Yes ❑ No
Was ihe app6anl fi5 yaars of age ar rtna on Oecember 31 of the year
o�ro� �o ma a�M y�n
❑ Yes ❑ No
Adjusted gross income of appliwnR spouse, and any
individuals sharing ownership (ForOver65 deduction, income
may not exceed 525,000; for the Over 65 Circuit BreakerCredit,
income may �rot exceed $30, 000 for individuals, or 540, 000 for
married coupfes).
Mave you fded for airy
HavayoulJad
� Yes
any othar muny?
❑ Yes
Over 65 Circuit Breaker Credit
H owned wkh mmeona other than spouse,
i�i�ata with whom
Is Ihe pmperty in Question:
Real properry � Mobile home (IC 57-1-�
Record number Page number
_��
Assessed valua of 1ha property az of Ma(ch 1, artrefn year (may rof ai�ed f 782,430
!or Orer 65 dedudian, v S1fi0.000 hr Ne 0.er 65 C'vcvf Bieal�r GediQ
Appfuam's date ot buth (mmN. daX Y�0 If (Jed by a survrving� unrrertied spwse.
what was the spoum s age a1 the time
�
$
VWe certi(y under penalty of perjury that the above and foregoing infortnation is true and correct and that tha applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
at,�p,�i�m / �`��rZi�`Z Sne.�e �o� osa�. �acoee�
' //
Address of au1�w'rmtl represenhative (nunberaMSheeC uty �ate, antl