HomeMy WebLinkAboutAge_Conaway' > APPLICATION FOR SENIOR CITIZEN
:- . PROPERTY TAX BENEFITS
•S ; Stata Farm 43708 (R9 / 9-0e)
Prescri6ed by Na Departmerrt o( Loral Govammerit Fnance
Infortnation coniained in Nis dacumenl is CONFIDENTWL pursuant to IC 6-1.1-72-9 and IC 61.1-35-9.
wsrnucnoNS:
COUNTY TOWNSHIP YEAR
JAN 2 2013
To be filed in parson or by mail with lhe CountyAud�ta of fhe pounty where the pvoperty is locatetl.
Filing Dates: 1) Real Property: Dunng the twelve (12) monfhs be%ra December 31 of fhe ysar the deducfion is t
2J Mobde Homes assessed urMer IC G7.1-7 0� manufacfuretl hanes not assessed as re�� ' 12)�pnR s
6eloie March 37 oJthe yearthe deduction is to be ellective. ��� V
See reverse stle (w addilionel insWdions arM qualificafians
Type d benef,t requa5etl (ploase rheck e0 fhaf appty)
� Over 65 Deduction 6om Assessed Valuation � Over 65 Circuit Breaker Credit
Name d appfrant (awnw or cmlr�act bvyo�
'J�r r ` � G rl w a
Is applv�n Ure sde lepal or equitade ownaR If No, what is Aisiher exact share or iMere57 H amed wiih sanaone other ihan spouse.
��ta wilh whom
� Yes ❑ No
H name on remrd'a tliRererit Ihan that of appfiranl iMiceta bebw
Name d cant2d se�er (app(mant musf have been buyv�g m contract at kast one (i) yeaiJ
Pdd�ass d mntrad w0er (number aM sbaeL �+ty, state, eM LP mde) Is Na P�7erty in Question:
Real pmperty � Mobile homa QC fr7-1-n
Ta�cing distncl Kay numberl Legal Eesuiplion Record number Page num6er
' �� O �b ��
Is the Wopery used aM oceupiad prima y(or Assassed valua of tha pmpefty az o( Mamh 1, wrter�t year (may rrof exceed f782,430
hi4her residBnca? tw 0`er 65 detl�dim, � E760 000 Por fha Over 65 Circitif &eakerC�edi�
Yes ❑ No
Was Na appGraM 65 years of aga or mora on December 37 of Iha year
Adjusted gross ineome of appliwnt, spouse, and any Source of Inwme Amourtt of incoma
individuals sharing ownership (ForOver 65 deduction, income $
may not exceed 825, 000; for the Over 65 Circui[ Breaker Credit,
income may rrot exceed $30, 000 for individuals, o� 540, 000 (or $
married couples).
TOTAL 5 0.00
Hava you (ded for arry dher deCumons? It 14s, what tletluctions7
� Yes ❑ No
Mave you t3ed for daductions in any other mu^tYl tl Yes. what muerty7
❑ Yes No
UWe certify under penalty of perjury that the above and foregoing infortnation is true and correct and that the applicanl was a residen[
of Indiana and owner of the aforemen6oned property on March 7, 20 _
Signalu app�uant Addressofapptiram (nunGeraMstrea4dry,s7alo.aMZlPwde)
/ .� �� 6 �
Sipnature ot authwaed rep�esentaw Pddress af auUar�d raprewntative nunGer aM atree4 �Y, sfata, and LP aode)