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"' APPLICATION FOR SENIOR CITIZEN couN � o NSHI r i
, PROPERTY TAX BENEFITS I
` -' StateFOrtn43708lR9/40B)
� PrescnbeE by Me DeGartmerrt of Lonl Govemment Finance
File Mark
Iniwmation eontaineC in Nis Oocvment is CONFIDENTIAL pursuanf to IC G1.1-12-9 and IC Cr1.1-35-9. C� n1 -� �,
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iNSrnucnoNS: v
TobefifedlnpersarorbymaiiwifhtheCouMyAUditaolthewunrywheretl�epropertyislocated. GIBSONCOUNTYAUDITOR
Filing Dates: 1) Real Prvperty: DuAig the IweNe (12) marrths be/ae December 37 of the ysar the deduction is to be eNective.
2) Mo6Ae Hanes assessed urider IC &1.1-7 wmanWactured homes rrot assessed as real property: Dunrg the hreNe (72) months
be/ae Mart,i� 37 0/ the year the tleduction is to 6e eflective.
See reverse side (or edtlifional (nsWCtrons errd qualifications. -
TyOa d 6e�reft reaueated (P�ease Mecic a0 thaf appl�
� Over 65 Deduction from Assessed Valuation
�. «�� eNe�
la eoGliprtl Ne sde lepal or eQUitaHe wmeR
❑ Yes ❑ No
M name on reto�tl b diRerBM Uian
�^rl
Name of mitrad saAer (epplicant must fwre Eeen buying on cmMac7 et basf oire (iJ yearj
MER99
Is Ne propeM � a'k occudad pnmariy for
hivhar rea'den�7
� Over 65 Circuit Breaker Credit
If ownetl with someone other lhan spouse,
inEiote with whom
y, stafe, and ZIP wde) �s the o�Gerry in auestion:
�.Real property � Mobile home (IC 6-74-n
Key number / Legal dascnpiion Record number Page rumoar
b -/`f-.�o -/oo-oDO. �b'd-oo b
Assassed value ot lhe properry as ot March 1. wrreM year (may rmf exceeC Sr82,a30
Ior O�er 65 tlotlurlian, w 5160.000lor Me Over 65 C"uctul &eakc� CreQi�
�Yes ❑ No
of ape or mo�e on December 31 af lha year
_ �Yes ❑ No
Adjusted gross income of applicant, spouse, and any
individuals sharing ownerahip (For Over 65 deduction, inwme
may not exceed b25, 000; !or fhe Over 65 Circuit Breaker Credit,
income may rrof exceed 530,000 /or individuals, or 540,000 for
married couples).
Mave you fiied for erry dher Eeductiona7
�Yes
EeEuctions in any olhar cwrrty?
� YCS
� No
� No
I/We ceAify under penalty of perjury thal the above and foregoing information is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
dacd�m
Addresa of aOC����� (numbei and street. ciry, slate, aM Z/P code)
Address of autMrized rapresentativa (number arH slreet city, stafe, antl LPcrodeJ
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