Age_Riggs� "'"o APPLICATION FOR SENIOR CITIZEN couNrv TOWNSHIP veAa
,__ ; PROPERTY TAX BENEFITS
•S -, Sqfa Fortn 43708 (R919-08)
Prescnbed by the Oapartmam of Local GovammeM Flnance
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Informatiw� wntained in Nis tlowment is CONFIDENTIAL pursuant tn IC 6-1.1-12-9 and IC 61.1-359� �
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INSTRUCTIONS
To be Retl in person or by mail with the CountyA�tli(wol the munry whera Ihe property is located. f1EC 2 � 2� ��
Filing Dafes: 1) Real Property: Dunng the tweNe (12) months belore December 37 of the ysar the tleduc6on is lo be e/feclive.
2) Mobile Homes assessed uiMer IC fi1.1-7 or manu/actured homes rwt assessed as raal pLop��fY�B�Ne (12J months
6e�we Marfi 37 of the }rear fhe deduction is to be eRective.
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GIBSON
TypBNbaneHrepuesleE�please e➢Natapply)
Over 65 Deduction from Assessed Valuation er 65 Circuit Breaker Credit
Namedapplram(
No, what is hisfier enad shara w iniarest? It ow swneone other ihan spouse,
iMitate � whom
❑ Yes ❑ No
If name on record'u diflerant ihan that ot applicant, indicate belaw
r+ame m mr�ra seDer (appGwnf mtat have been buy'vg m cmlydcf af leasf o�re (1f ynaQ
Atldress of �(number aM sbeeL �; stab, erW LP mde) Is lhe ptopetry in question:
� Real pmperty � Mobile home QC �74-�
7yii�g ' Kay numCer / Legai descnpfion Recortl number Page numbar
a�- i�3-b�-�-�. a�
Is Ihe popeM usad e ocapiad ' y for Auessed value of the pfoperty as o( Mamli 7. curtarit year (may rot erraed E782,430
hisfier rasidence7 lai O�er 65 dedvdim, n Si60,000/or Ihe Ovr165 C'unit Brealar Crad'rQ
Yes ❑ No
Was Iha appGram 65 years of age or mwe on Dacember 31 of ihe year
Have yau fAad ta a(ry othar detluctions7 If Ves. what ded�ctions7
� Yes No
Mave you @ed fa deductions in any olher cwrity? If 1§s, what couMy7
� YCS O
IIVJe certify under penalty of perjury that the above and foregoing information is true and conect and that the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20
Signature d ra C Adtlress af appliranl (nvnbrr eM sboaG aN, sfata. aid ZIP wtle) .
�7 O- `/ `�/�"F li% S�Zs S l s �.L . `/7GG _
Signature dauNOrized rapreserM1ative Address of aWhorized reprasantative (namberarH sLOef, cdy. 9afn, and LP co0e)