Age_Fark•^`°�^ APPLICATION FOR SENIOR CITIZEN COUN7v TOWNSHIP YEAR
ab � ' PROPERTY TAX BENEFITS
5•�• Sta:eFwma37o9(R7o/12-0e) ������
•�` l Prescnbed by the Department of local Govemment Finance �
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
DEC 29F20
INSTRUCTIONS: n �'
To be filed in person or 6y mail wi[h the CountyAudito� o/ the county where the property is located. �j `y�;�1—
Filing Dates: i) Real Property: Dunng the hvelve (72) months before December 37 of the year the dedu��S�bE 3�({Ey�AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property: Dunng the twe i(72) months
before March 31 of the year the deduction is to be eNective.
See reverse side !or additional insWCtions and qualifications.
Type of benefit requested (please check all that appty)
�; Over 65 Deduction from Assessed Valuation [� Over 65 Circuit Breaker Credit
Name of applicant (owner or contract buyer)
�7/� V �
I5 applifant Ne sole legal quitable ownerl If No. what is hisfner exact share or interest? If ownetl vnth wmeone other
indiwte wilh whom
� Yes ❑ No I
If name on remrd is diRerent than that of appliwnt, indicate below
Name of mntract seller (appliwnt must have been buying on contracf at /east one (7) year)
Address of contract seller (number and s�reeG city, sfa(e, and ZIP code)
Taxing dist� � Key number / Legal desaiption
�j���(.���/
Is the property used and occupied primanly for
�isRierresidence?
Is the property in question:
❑ Realproperty ❑
Record number
- /a - 07 - �o/-o°! �/ s-�.� s
Assessed value of the property as of March 7. wrrent year
lor Over 65 deduction, o� 5760.000 Ior the Over 65 Ci¢vit 1
�Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
prior ro the year taxes are first due and payable? ��
lLC Yes ❑ No
Adjusted gross income of applicant, spouse, and any
individuals sharing ownership (For Over 65 deduction, income
may not exceed 525,000; for the Over 65 Circuit Breaker Credit,
income may not exceed S30,000 /orindividuals, or 54Q000 for
mamed couples).
Have you filed fw any oNer deductions?
� Yes
Have you fled for deductions in any other county?
❑ Yes
ApplicanPS date of birth (montb, day, year)
`t-3o—y�
Source of Income
II Yes, what deductions?
❑ r,o %� S
If Yes, what county?
�' No
spouse,
�ile home QC 6-7-7-n
Page number
5782,430
If fled by a surviving, unmartied 5pouse,
what was the spouse's age at the time
of death? I
Amount of Income
S I
$ �
TOTAL I S
� ��
IIWe certify under penalty of perjury that ihe above and foregoing information is true and correct and that the appi cant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
SignaWre ot applicant Address of applicant (numberand street ciry, state, and ZlPcode) I
� �
x`y � � 3 � 8�_St';���ce s' PR�NC� I aili.o � 767 v
Sgnature of auttwdze0 r resentative Addre�ss'of authorized representative (number and s7reet. city. sfate, a ZIP wde)