Age_Andriakos o"w APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
r .; . 4 PROPERTY TAX BENEFITS
"ma State d by 43708
the (ep Department I '
mar Prescribed by the Department of Local Government Finance
ark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
SEP 2 9 2014
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. t
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the year the dedu• i, .••f+— yiy%ih r.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessee$&GJ !elrrpg,' =,tMem f 12)months
before March 31 of the year the deduction is to be effective. L11 I OR
See reverse side for additional instructions and qualifications.
Type of benefit requested(please Mock all that apply)
LA Over 65 Deduction from Assessed Valuation ® Over 65 Circuit Breaker Credit
Name of( -
aapppli_cant(owner or contract buyer) PP
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
4 Yes ❑ No
If name on record is different than that of applicant:indicate below
Name of contract seller(applicant must have been buying on contract at least one(I)year)
Address of centred seller(number and sheet city,state,and ZIP code) Is the property in question:
❑ Real property ❑ Mobile home(IC 6-1-1-7)
Taxi istrid k Key number/Legal description Record number Page number
/2 v e26s /A-O9 -IO`f-DO0- oyg-OX
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)
XIYes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
❑ Yes INo
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 .
Signature of applicant Ira Address of applicant (number and street ,state,and ZIP code)
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Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)