Age_Williams (2) ,•7;:.,R. APPLICATION FOR SENIOR CITIZEN COUNTY OWNSHIP YEAR '
.'`'�'4 PROPERTY TAX BENEFITS
State oFbed by (e9/9-08) Ti
S •... � Prescribed by the Department of Local Government Finance ED i
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
FEB 2 8 2014
To be filed 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 t• •: :1: le- �i
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as rea • • T f -•.,. (12)months
before Mardi 3)of the year the deduction is to be effective.
� � AUDITOR
See reverse side for additional instructions and qualifications.
Type of benefit requested(please check act that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant`(owner or contract
y ntracctt b/uyer)
•
i�`e {e. /1 a h)i
Is applicant the sole legal 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
If name on record is different than that of applicant,indicate below
Name of centred seller(applcant must have been buying on contract at least one(1)year)
Address of canted 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
.26 -!3-/3 -30o _ oo/.0.32 -ct
Is the property used and occupied pnmanly for Assessed value of the property as of March 1,current year(may not exceed 5182,430
hisrner residence? for Over 65 deduction,or 5160,000 for the Over 65 Circuit Breaker Credit)
VI Yes ❑ No
was the applicant 65 years of age or more on December 31 of the year
❑ Yes ! No
IAVe certify under penalty of perjury that the above and foregoing information is two 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 street,city,stale,and ZIP code)
) L �� ���-� 165/ 0 , ias 5- CnOK�I�„aC-i-y ,s,,`17(3(4a
Sure of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)