Age_DeWeese •
'":."a APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR '
``7-'1 PROPERTY TAX BENEFITS `
'f''-_.. Prescribed by (e9/9-08) F T �J Fi �..J
7:71- Prescribed by the Department of Local Govemmem Finance
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-11-12-9 and IC 6-1.1-35-9.
OCT 0 J n 2013
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor 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 -
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed Baia?Qfdre.OtONjwetyonyiT9Rnonths
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 chock all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name off applicant(owner or contract_buy-er) _ n /(n/s
Is appGCad the sole legal or equitable own//1/ If No,what 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 applicant indicate below
Name of contrail seller(applicant must have been buying on caetracf at bast one(1)year)
Address of contract seller(number and street,city,state,and ZIP code) Is the properly in question:
❑ Real property ❑ Mobile home(IC 6-1-1-7)
Toxijn�strict Key number/Legal description Record number Page number
�'/z�r�c� r— a& -is-07 - ;0/-0001. 679.5.0.1. 8
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$160,000 for the Over 65 Circuit Breaker Credit)
pYes n No
Was the applicant 65 years of age or more on December 31 of the year
of death?
Adjusted gross income of applicant, spouse,and any
Have you filed for any other deductions? IIIIII If Yes,what deductions?
������......IIII
Yes ❑ No NS
Have you Ned for deductions in any other county? If Yes,what county?
n Yes I
lNie 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 .
Signature of applicant Address of applicant (number and sheet city,state,and ZIP code)
' .Y/0 ZG - r � 8i7 Al. Race S pr,„TN 1N_ `t7G7o
ignature of authorized representative Address of authorized representative (number and street city,state,and ZIP code)