Age_Maikranz-Hill set APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS WM1 �o� ,
State Forth 43708(R13/4-15) (�, .�/1 vTI eN 2o 19
Prescribed by the Department of Local Government Finance
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS:To be filed in person or by mail with the CountyAuditor 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 following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property During the twelve(12)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(please check all that apply) rrrrAA
Over 65 Deduction from Assessed Valuation f2rJ Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
rQnZ- • t l �
Is applicant the sole legal or equitable amen 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 appli ant,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 blaming deduI- �ct-ioIn?
\� ❑ Yes L7No
Address of contract seller(number and street.city,state,and ZIP code) Is the property/ in question:
•
(r Real property ❑ Mobile home(IC 6-1-1-7) •
Taxing district Key number/Legal description Record number Page number
-otr40n -.( 0aIki2 aoD- ooa ta\ - ao �
Does applicant reside on property? Aesaccad value of the ppmrr�p�-rty aso of current year assessment date(may rat exceed
�-y S1e2,430/or Over 65 Dedudiorr or 5159,999(cormtbg just the homestead site)for the Over
Ld Ye5 ❑ No 65�-0t Breaker Credt)
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 fled bye 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 -Li � a Amount of Income
applicant and joint tenants or tenants in common,as �J �l®/ `�
applicable(For Over 65 Deduction,income may not exceed $ GO
$25,000;for the Over 65 Circuit Breaker Credit, income may not JUN 0 7 201 $exceed$30,000 for individuals or$40,000 for married couples.).
9
See reverse for details. • TOTAL $ 0.00
Have you fled for any other deductions? CIBb fV`[ses?
r�1 0 Yes CI No �V • AUoirdo
Have you fled for deductions in any other county? ,�,/ If Yes,what county?
❑ Yes IBNo •
•
UWe certify under penalty of perjury that the above and foregoing information is true and correct. •
'.
•
Signature of applicant Address of applicant (number and street.chi state,and ZIP code)
1V�" hiAlt es( or w 80O 6 � i, „�„�X/. ma`
Signature of authorized representative Address of authorized representative (number and street.d4ty,thee,and[- - - - - - - - -- --- - -- -- - -- - - - - - -