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Age_White (2) d "a APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP I YEAR e-- PROPERTY TAX BENEFITS 5•i• State Forth by Department 15) $� L: ,at •' Prescribed by the Department of Local Government Finance t� IL 111 1117��F�ile Mark Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. MAR 6 2018 INSTRUCTIONS:To be filed in person or by mail with the County Auditor of the county where the property is located. Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmark) hyi moor- Filing uaarpry 5. 2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed tgsIr3fgpsrty.DGigllid TTI31IQ•r12)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(pie e check all that apply) ❑ Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit Name of applicant(owner or contract buyer) C l /r1 L � r� ' Is applicant the sole legal or equita a wner? j If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common, indicate with whom ❑ Yes ❑ No If name on record is different than that of applicant,indicate below Do all joint tenants or tenants in common reside on the property? ❑ Yes ❑ No Name of contract seller Has applicant owned or been buying the property under recorded contract for at least one(1)year before claiming deduction? ❑ Yes ❑ No Address of contract seller(number and street.city,state,and ZIP code) Is the property i uestion: Real property ❑ Mobile home(IC 6-1-1-7) Taxing district Key number/Legal description Record number Page number a :,- 13- - 4.00-0:)[. ©l(o-Obh Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed $182,430 for Over 65 Deduction or 3159,999[counting just the homestead site]for the Over No 65 Circuit Breaker Credit.) ❑ Yes ❑ See reverse for details. Is the applicant 65 years of age or more on December 31 of the year Applicant's date of birth(month,day year) If riled by a surviving,unmarried spouse,what prior to the year taxes are first due and payable? was the spouse's age at the time of death? ❑ Yes ❑ No Adjusted gross income of applicant,applicant and spouse, or Have you filed for any other deductions? If Yes,what deductions? ❑ Yes ❑ No Have you filed for deductions in any other county? If Yes,what county? ❑ Yes ❑ No I/We certify under penalty of perjury that the above and foregoing information is true and correct. Signature of applicant Address of applicant (number and street,city,state,and ZIP code) G�.,zt4 -m • c�J . 5 Lure of authorized representa r Address of authorized representative (number and street,city,state,and ZIP code)