Age_Birch Ca APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
e ' PROPERTY TAX BENEFITS
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\` State Form
4by the ep3/415)
\,<�:C. Prescribed by the Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. OCTpit
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located. ` ` 4 2018
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked(��� by ,-'flowing January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real raga r I' .•r4::ry•',I. ..oaths
before March 31 of the year the deduction is to be effective. O(J(1fTy A
See reverse side for additional instructions and qualifications. 'Jo,TOR
Type of benefit requested( ease check all that apply)
Over 65 Deduction from Assessed Valuation jI Over 65 Circuit Breaker Credit
Name of applicant(owner or contract
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Is applicant the sole legal 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
ICI 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 in question:
❑ Real property ❑ Mobile home(IC 6-1-1-7)
Taxing sM Key number/Legal description Record number Page number
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Does app scant resid on pr rty? Assessed value of the property as of current year assessment date(may not exceed
S 182,430 for Over 65 Deduction or$159,999(counting just the homestead site]for the Over
Yes ❑ No 65 Circuit Breaker Credit.)
See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
Have you filed for any other deductions? ��` ---���!!f If Yes,what deductions?
/cS �y[J Yes ID No ��
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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 a plicant r I Address of applicant (number and street,city,state,and ZIP code)
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code) 17670