HomeMy WebLinkAboutAge_Adcock..#�" APPLICATION FOR SENIOR CITIZEN
�_ PROPERTY TAX BENEFITS
State Fortn 43108 (R9 / 498)
•O � Prascnbed by Ihe Oepartment o( Local GovammeM Flnance
In(ormatiom m�tained in Nis tlocument is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 61.1-359.
TOWNSHIP I YEAR
INSTRUCTIONS:
To be filed in person or by mail wdh fhe CountyAUditor o/ fhe munty where the {voperty is locatetl. � C j 2 6 Z O,�
Filiry Dates: 1 J Real Property: Dunng the hvalva (12) mmths befwe December 31 0! the year fhe deduction is to 6^eHecfirve.
2J Mobile Homes assessed urMer IC 61.1-7 or manNactured hwnes rwt assessed as reel property Duri'rig�7�e�(�§l� (12) months
be/we March 37 07 tAe year the deduction is to be eflecfive. ����
See reverse sr�e for adddional insWClions aiM qualificalims. C' �BS ON COUMTY q UD I TO
TyPe of benef.l ra7ua5ed (pleasa dieck a9 Nat aPPN)
� Over 65 Deduclion 6om Assessed Valuation �Over 65 Circuit Breaker Credit
cantraa nvyetl
b appfimM lhe sole legal ar equitade ameR If Na, whal'u his/her exaU share w
❑ Yes ❑ No
It name on ramd "n tliHerent Ihan ihal o( appircant inGicete 6ebx
(appr¢anf mus! nare eoan buying m cmrrad af aa5 0� (iJ year)
lddress d mntraa mller (number aM sbeeC �y, sble, aM LP wde)
Ta�cing d'a Key numbar / Legal aav
��C� %, �-oy-zU �
U �he P�WaM used and ottuP�ed pr'vnariN br�
hisTharraziEenm) �
� Yes ❑ No
Was Ihe appGcar�t fi5 years of ape a rtrora on Oacember 31 of Ihe year
pnor to I�a wrtam yea(!
� Yes ❑ No
Adjusted gross income of applicanR spouse, and any
individuals sharing ownership (ForOver65 deduction, income
may nof exceed 525, 000; for the Over 65 Circuit Breaker Credit,
income may rrot exceed $30,000 forindividuals, or 340,000 for
married couples).
you fded (v arry Mher tletluctions7
� Yes � No
Have you filed far deductions in any aher muMy?
�Yes ,�No
Is lhe pmpe(ty
�Real pmperty � Mobile home QC G74-�
Recortl numbar PaBa num6er
/ o0G ao 5 -o�� I
AcsesseE vaNa ol the poperry as of Ma(rh 1, wrteM yaar (may rwt osceo0 E7B2,430
fwOrer 65 de0ud"w; or f160.000 foifha O�m165 Cw,cu! &eaimr CrediQ
IIWe certify under penalty of perjury that the above and foregoing information is We and covect and that ihe applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20 _
7nature d appficar� Address of appGmnt (num6or antl sboeL uN, sbte, aM Z/P mAO)
C�'
Signalure d authorized re0���aN'e I Addmss of aNhwicad represantativa (nwnbor aM sLOef. dry, stete, and LP cotlo)