HomeMy WebLinkAboutAge_Blanton"'" APPLICATION FOR SENIOR CITIZEN couw7v TOWNSHIP YEnrs
,_ - s PROPERTY TAX BENEFITS � �� T
State Form 43708 (R9l 9-08) g J
,' "� P�ewibad by the DepartmeM of Local GovammeM Finance
Fle Mark
Informafim mntained in this tloaiment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC G1.b35-9. �EC 1'3 Z0�2
INSTRUCTIONS C �
To 6e 117ed in person or 6y mail wrfh fhe CountyAud"Ror o7 the county where fhe property is located.
Filing Dafes: 1) Real Pioperty: Dun�g the tweNe (72) mmths be(ore December 31 o/fhe year the deduction is tq_� g O ���TY� ���R
2) Mo6ile Hanes assessed under IC 51.1-7 ormanu(actured hanes ral essessed as raal property�' unrg (�
befae Marc� 31 0! Ne year the deduction is to 6e eRective.
See reverse side !o! edditional ins6uc6ons aM qualiRcations.
Type d banePo reque9ed (please rhatlr a0 Nal appl�
� Over 65 Deduction from Assessed Valuation ,�Over 65 Circuit Breaker Credit
Name d appficaen (ow+ror or cmtracf Ouyeh
/ — ' ��l-!'�"C.C//�O / "'
Is applicairi the sde lepal or eQUitaMe owne/! tl No, whal is hisTher exad share or irrteresl7 If owned vrith mmeona olhar lhan spouse,
indimte with whom
❑ Yes ❑ No
1( name on �ecad'a aMarenl Ihan tliat at app(vn4 ��4�ie bebw
Name at mntreri setlar (app/icant mv5f have been buy"ug m ronlydcf af /easf orre (i) yrar)
Addrass of mntratl sa0er (numDerand sheeL city, sble, aM ZIP wde) Is fie pioparry in Question:
� Real pmperty � Mobile home (IC G7-i-�
distrir� Key number / Lepal dascnption Record number Page num6er
.�a� a� -I�-l� -� oo -000 . � � s-�a
Is �ha prapa`fy used anE attupied rily br Assessed value of �he poperty az o( Mamh i, curtani yaar (may rwt erreetl SiB2,430
hisThef rasitlents7 (o/ O�er 65 Eedurl:an, or 5160,000 /oi NB Ove/ 65 Cirudt &eaka! CrediQ
� Yes ❑ No
Was ihe appGCart165 yaars of ege or rtare on December 37 ot the yaar Applica^I's date of birth (month, tlay, yeeQ I( (led by a wrviving, unmartietl spouse,
prior to iha airtarrt yeaR what was lhe spousa a age at the Wna
�Yes ❑ No �/� /� �/' ofdeam?
Adjusted gross income of applicant, spouse, and any Source oi Inwme nmourrt oi Income
individuals sharing ownership (FOrOver 65 deduction, income / O O n $/a � d
may not exceed $25,000; (or fhe Over 65 Circuit 82akerCredit, �"/
income may not exceed $30,000 Ior individuals, or 540, 000 for $
married couples).
TOTAL $ 0.00
Have you (dad far a'ry other deEUCGOns7 If 1§s, what dedumons7
�Yes ❑ No !7 S M �"
Nave you filatl tor Getludions in any other munry? if Yes, what counly7
❑Yes ❑No
UWe certify under penalty of peryury lhal the above and foregoing infortnation is trua and cortect and that tha applicant was a resident
of Indiana and owner of ihe aforementioned property on March 1, 20 _
Signature d applicant Address of aOV��nt (num0or and stroef, dty, sFab. arid ZIP code)
� ` JC 77 �SS �7l070
Signatura dauthorized tepresentative Address o(aNhor"rmtl represenfativa (mvnDerarM s1reoL a+ty. state, end LP wdo)