Age_Jackson APPLICATION FOR SENIOR CITIZEN COUNTY I TOWNSHIP I YEAR
-till PROPERTY TAX BENEFITS gI{ yyI
\, ' State Form by the ep0 t 1e-08) F A I T ., F I)
\ � Prescribed by the Department of Local Government Finance IAAYI AAA ,
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. APR 18 216
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. I •_a d
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the year the deduction 8(0-6.44- • •. ��TTy�ypp�'LL''rr��'���nr�1p
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real pro erty::During t e relvB tT7/7Y1dn ti
before March 31 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Type of benefit requested lease check all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of app' nt(owner or contract buyer) (� (�
/ i.1- /� f AEC al /l ,e• / i ,X..)
applicant the sole legal or equitable owner? If No what is his/her c share or interest? If owned with someone other than spouse,
indicate with whom
❑ Yes n 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(1)year)
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
Real property ❑ Mobile home(IC 6-1-1-7)
Taxin district 'Key number/Legal description Record number Page number
X—i 4917A706—oa°. 27
Is the property us 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 5160,000 for the Over 65 Circuit Breaker Credit)
❑ Yes n No
Was the applicant 65 years of age or more on December 31 of the year
❑ Yes ❑ No
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 Address of applicant (number and street,city,state,and ZIP code)
Y'' litlai n ,� a i j S ( OO'
G A 04 /cio.lof C ,5, 2A/ V26 6, o
Signature of authorized refsentative Address of authorized representative (nurhber and street,city,state,and ZIP code)