Age_KocaAPPLICATION FOR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
State Fartn 437081� / 408)
� -� PrescAbed by Ne Oepartment ot Loral GovammeM Financs
Informatiom m�tained in this doaiment is CONFIDENTIAL pursuant to IC 6-t.t-12-9 antl IC 61.135-9.
INSTRUCT]ONS:
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DEC 1 9 2012
To be filed in person or 6y mail widt the CountyAUtldor o! the county where fhe property is located. �C �
Filiry Dafes: 7) Real Pmperty: Dun� the tweNe (12) montf�s be(ae Decem6er 37 of the year the tleduction is to ba e7factive. �1�J ��
2) Mobile Homes assessed urrder IC b1.1-7 oimanu7acturetl homes rrof assessed as real property� n the twahe ( s
6e/we Marrh 31 ollhe year the deduction is fo be e(fecfive.
GQ�S�SN COUNTY AUDITOR
See reverse sde /or atldXionsl inshudions end qualifications
Type al benef.t req BscaE oasa Mack a8lhat appiy)
Over 65 Deduction from Assessed Valuation Over 65 Circuil Breaker Credit
Nama d apqicam (o»,ior or carmact ovyeQ
�
b applimM the sde legal or eQuilade oxne(1 If No, what u hislner azaa shara w iriterestl H owned with someone ather Ihan spouse,
iMimte wilh whom
❑ Yes ❑ No
If name on racwd is diRerent fhan that of appl&an� indiceta bebw
Name d contrad seller (appGCant must have bean birying m cantract af loast orre (1J yeaQ
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Addrass ot mntratl sellar (number aM sbee4 �N• slab, ariC ZIP cotle) �s Ne pmpeNy in Ouesibn:
�— Real property � Mobile home (fC fi74-n
Tar.i d'atrict Kaynumber/Legaldescnption Recordnumber Pagenumbar
� G- a-o� -o�d.�s��Qaa�
La ihe property used and ocaped primariy for Acmaed value o11he qope�1y as al Ma(ch 1. wrre(rt yaar (may imf uceed f182.430
his/net resitlanm7 Ior O�er 65 deduCiyi, or Si66,000/or Iho Ovar 65 Cirtr�it &ealsrCiadi�
❑ Yes ❑ No
Was the appGant 65 years ot ape w mua on OecemEer 31 of Iha year
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Hava yau filed for arry Wher ded�xliDns7 If 1§s, what ded�cCOre1
� Yes � No
Hare rm �ed ror eed�cuons in any at,ar camry? u ws. wna� ca,my?
❑ Yes ❑ No
IIVJe certify under penalty of peryury lhal the above and toregoing information is true and cortect and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March t, 20
Signatura of appfrartl AEdress of appli�nf (mmber aid sLOeL tiry, sfafe, aM ZIP cotla)
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r�, ' 7 � 7 a
Signatu`eo(auNwizedrepreseMalive Addressofauthorizedrapresentative (numberarMsGOe4�Y.��o,endLPwdo)