Age_WilliamsAPPLICATION FOR SENIOR CITIZEN
..� PROPERTY TAX BENEFITS
�'�:,'• Sbte fwm 43708 (R919-OB)
`� Prascnbed by tha DapartmeM of local GovemmeM Finante
Information oontained in this dowment is CONFIDENTIAL pursuant to IC 6-1.L72-9 antl IC 6-1.L35-9.
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wsrRUCnoNS:
COUNTY TOWNSHIP � YE�
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��jjO/M
DEC 3 1 2008
To 6e filed in persm or by mail wifh the GourrtyAutlita o1 the wunry where fhe property is locafed.
Filing Dates: 1J Reel Property.' Dunrg the tweNe (12) months 6e/ae Decem6er 37 o7the yser the deduction is fo 6e s
2J Mobile Hwnes essessed under IC &7.7-7 or manulectured homes not assessed es real pmperty: Dunrtg the w�l �12J nfhs
6efore MarGr 3f o(Ne yearfhe deducbon is to be eflective. GIBSON COU�!TY AUDITOR
See reverse sitle !a adddional lnshuGions arM qualificafions.
Type of benefi reQUesied (please Mxk a0 Nat appl�
Over 65 Deduclion hom Assessed Valuation Over 65 Circuit Breaker Credit
Name o( � o✓ cmtrect 0uyoh e .
O � � �� /�
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Is aoolicarit tha sola legal oreavitabla owne(� If No, what is hislher exad share or interest? I! owned with mmeone o�her than spouse,
indiptewithwhom •
❑ Yes ❑ No
If name w rewN is CiRarant Nan �hat ot a00�rt, indiwte bebw
Name W mntad 6eDer (apP4canf musl Axve been E�yilg or� cm:ract at loast or�e (t) yca�
AdCress ot contrad seliar (numGaa�M swet, ciy, stafo. aM ZIP code) Is the pmoetly ir Quastior.:
� Real pmpery � Mobile homa (IC 6-7-7-�
Taain9d'u�nn Keynumber,/�_L[g�palanescriotion/y7 �y� j'� �Re/co}r�dnumber Pager.umoar
� ���� 7�� /_ �6..c/'W� ��dl-'VU�
Is Na pmOeM used and occu0ied pri anly b 0.ssessed value of the pvoerty as of March 1, cunent year (may not excactl 5t82,430
hisrTar residanw7 far Owr 65 tlotlucfion. w 5160.000lor l�o Over 65 Cvcuf. Bieaker Cretlrt)
Yes ❑ No
Was �he apWiprit 65 years ot age or more on December 31 ot the year A�olicanfs date of birth (mm:h, day yaaQ If f!ea by a survrving, un.mamad soouse,
o�orto Na currant yeaR wcat was the spouse's age at tr,e tima
Yes ❑ No / -�� . � ot deatn?
Adjusted g�oss income of applitant, spouse, and any Source of Income � Amount of Income
individuals sharing ownership (FOrOver 65 deduction, income I S I
may not exceed 525,000; !or the Over 65 Circuit Breaker Credil,
income may rrot excesd 530,000 fo� individuals, or $40, 000 /or I S
mamed couplesj.
TOTAL I S 0.00
Hava you filed Iw airy othar deEUCtions9 If Yes. wnat daductior.s?
Yes ❑ No yS. �
Have yw filed for deductions in any other counry7 ��'!es, what ca:nty7
❑ Yes No
IIVJe certify under penalty of perjury that ihe above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20
Signatureolappikam CEtassofa00�ifar.� (numDerandswef,ciy,sate.aMZlPwde)
� �✓� /,�6 � ao
Spnature of auNaized reo�esentative Addrass of aulhodzed rsa�eseniative (number and s:rea; ciry, sfate, and ZI _ad