Age_Keith Cyr w APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR '
"'" PROPERTY TAX BENEFITS F' I L E
-'', - - State Farm 43708(R9/9-08)
nes Prescribed by the Department of Local Government Finance EE1I� c
Information contained in this document is CONFIDENTIAL pursuant to IC 6-11-12-9 and IC 6-1.1-35-9. AI'K `.,� 2013
INSTRUCTIONS:
To be riled in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the year the deduction is to(3ii COUN Ty AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property:During the twelve(12)months
before March 31 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Type of benefit requested(please check all that apply)
ld Over 65 Deduction from Assessed Valuation II/Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
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Is applicant the sole legal or equitable owner? If No,Jet is his/her exact share or interest? If owned with someone other than spouse,
indicate with whom
❑ Yes ❑ No
If name on record is different than that of appfmant,indicate below
Name of contract seller(applicant must have been buying on contract at least one(1)year)
Address of contract seller(number and street city,state,and ZIP code) Is the property in question:
❑ Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
etre.amaLI L., sib-l3_11-02 ao_ocb.5'kO O01.
Is the property used and occupied primarily for Assessed value of the property as of March 1,current year(may not exceed 5182,430
his/her residence? for Over 65 deduction,or 5160,000 for the Over 65 Circuit Breaker Credit)
RYes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
Have you fled for deductions in any other county? If Ws,what county?
❑ Yes PaiNo
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1,20 •
ature of applicant Address of applicant (number and street,city,slate,and ZIP code)
X Gtf X /Q-Av— /05-0 -44 ,a' 47
Signatu (authorized representaW Address of authorized representative (number and street city,slate,and ZIP code) 7
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