HomeMy WebLinkAboutAge_Robb� �v APPLICATION FOR SENIOR CITIZEN couNrr sHi � r�
PROPERTY TAX BENEFITS
•� ' State Fwm 43708 (R9 / 9-OB)
Prasaibatl by Ihe DepaMmeM of Local Govammerrt Finance
Informatlom m�tained in lhis doamenl is CONFIDENTIAL pursuant to IC 61.1-12-9 and IC 61.135-9. V�'�� ���2
INSTRUCTIONS: � �7 � ��
To 6e filed in persm or by mail with the CountyAuditw o/ fhe county where the property is locatetl.
Filing Dates: 1J Real Property: Dunrg the fweAre (72) mmths 6efae December 37 oJthe year the deduction is to 6$�BJ COUNTY AUDIT�R
2J Mo6ile Homes assessed untler IC &7.1-7 ormanulactured hanes rrot assessed as rea/ pmperty: Dunrg the MsNe (72) montlis
6e/ae Mardr 37 olthe yearfhe dedudion is fo be eflective.
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See reverse side fa atldifional insWCYions arM qualifications.
Type d benef.t rapuested (please MxJc a� Nat apply)
W Over 65 Deduction 6om Assessed Valuation � Over 65 Circuil Breaker Credit
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Nameof pGaM(ox+wrwcmLactbayeQ
Q.�f-� �- ���
Is apO��M tha sde legal or eduitable wmeR w interest7 N o-xned with svmeone dhe� Nan spwse,
Indirvta with whom
Yes ❑ No
If name on recnd is dMarem Ihan Ihat of app6fant, iMicale bebw
Nartre o( mrt(ad seAer (aPPr+�nf must have be� buyirg m caRlacf af leasf orre (1) YearJ
ACtlrass of mntrad seller (nivnbor ariC sbaeL �'�y. sble, aM LP mda) Is the propaM in question:
Real property � Mobile home (IC Gf-1-�
d'¢triri � Keynumber/Legaldesuiption Recordnumber Paganumbaz
Q�S�- d�-Ga-s'7_o�G-a,o.G �-oi7
k Na pmperty used and occup' d rimarily for Asseuetl value of lhe properry as ai Mamh 1, wrterh year (may �rot exrced Sf82.430
his/hef �assiAanm7 tor O�er 65 Oedurlim, w E760 000 for fhe O�rer 65 Cticait Brtra,�mr Credit)
❑ Yes ❑ No
Wav the appGmm 65 years ot age or more on Decambar 31 af lhe year
$ � .
Have yau filed for any other dedudions? If Yas, what deductions?
� Yes � No
Hava you fileA tor deductions in any other munry? It Ms, what cwnty7
� Yes ❑ No
VWe certify under penalty of peryury lhat the above and foregoing infortnation is true and covect and that ihe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of app6caM Address ot appGram (nirtnborantl sboef, dty, sfate, andZlPmOO)
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Signatura d auNOnzed raprasantative ACdress of author'rced representaMe (nwn6oraM sbeef, city, slafe, and LP code)
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