Age_Moore tit APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
'i- / PROPERTY TAX BENEFITS
S•'%.,:% Pretscribed by the Department of Local Government Finance - ww
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
APR 17 2018
INSTRUCTIONS:To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the loll.l/•Janu. • .i
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real propertf . c • ff'i$T• I •'rinths
before March 31 of the year the deduction is to be effective.
• N AUDITOR
See reverse side for additional instructions and qualifications.
Type of benefit requested(please check all that apply)
Over 65 Deduction from Assessed Valuation
f Over 65 Circuit Breaker Credit
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Name of applicant(o//ner��,or contract buyer)
Al ,e6
Is t the so al or equitable owner? 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 diffe ent than that of applicant,indicate below Do all joint tenants or tenants in common reside on the property?
❑ Yes ❑ No
Name of contract seller Hasa applicant owned or been buying the ro
pp year b g la pnrty 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 in question:
X.
Real property ❑ Mobile home(IC 6-1-1-7)
Taxi isUict Key number/Legal description ! •Record number Page number
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
5182,430 for Over 65 Deduction or 5159,999(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 1 of the year
Have you filed for any other deductions? If Yes,what deductions?
Ve Yes ❑ No NJ.
Have you filed for deductions in any other county? If Yes,what county?
❑ Yes %No
WJe certify under penalty of perjury that the above and foregoing information is true and correct.
Sign.'- -of applicant I A cuss of applicant (number and stre city,state,and ZIP
a # X?k PAILe q i q - _S, Nyte,e,174,- . ei 7t 7)
Signature•f ,uthorized represeni ive Address of authorized representative (number and street,city state,and ZIP code)