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•'"' n. APPLICATION FOR SENIOR CITIZEN - (�'j�s YEAR '
e4.--. •% PROPERTY TAX BENEFITS
State Fond by 43708 the (R9/9-08) 'I��
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ou Pmvri6ed by Ne Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS: �7!/JI17[IYe/�N
To be filed in person or by mail with the County Auditor of the county where the property is located. (:II qptccr(��'N ((��O,,II NTY AUDITOR
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the year the deductioot sgd"be ececke.
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(pl se check a that apply)
Over 65 Deduction from Assessed Valuation ErOver 65 Circuit Breaker Credit
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Name of applicant(owner or contract buyer) // I '
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Is applicant the sole I gal or equitable owner? If No,what is his/her exact share or interest? If owned with someone other than spouse,
indicate with whom
❑ Yes ❑ No I
If name on record is different than that of applicant indicate below I
Name of contract seller(applicant must have been buying on contract at least one(1)year)
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Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
❑ Real property ❑ Mobile home(IC 6i1-1-7)
Taxing district Key number/Legal description Record number Page number
74 a..,..",-,40,1e- 26.11.34-Y03 -000. AO7.009
Is the property used and occupied primarily for Assessed value of the property as of March 1,current year(may not exceed 4182,430
his/her residence? for Over 65 deduction,or S160,000Ifor the Over 65 Circuit Breaker Credit)
Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year Applicant's date of birth(month,day,yew)
Have you filed for any other deductions? If Ws,what deductions?
['Yes ❑ No H S
Have you filed for deductions in any other county? If 1Ss,what county?
❑ Yes ❑ No
Uwe 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 1
Signature of applicant Address of applicant (number and street,ply.state,and ZIP code)
C.1 Arra ar...../ / ! X/�,S .S_ �� .ice, 'ar-I �...i. _Se j6 S'
Sign. are of authorized representative Address of IF orized repro;:.:ntative (number and street,city,state,and ZIP code)