Age_Keenan� � APPLICATION FOR SENIOR CITIZEN
- PROPERTY TAX BENEFITS
� ` ... , !' Spla Fam d3708 (R9 / 408)
Prexnbed by Me Departmem oi Lacal Govemmem Financa
Information eontained in this tlocument is CONFIDENTIAL pursuant to IC 61.1-12-9 and IC G7.135-9.
wsrRUCnorvs:
� COUNTY TOWNSHIP � YEAR
Fi r
MAR 0 2 2009
To be filetl in person or by mail wilh the CountyAUdRa ol fhe county where fhe property is located.
Filirg Dates: 1) Real Property: Dunry the tweNe (72J monfhs before December 31 o7the year the deduction is t ective�. ,(��
2) Mobile Hames assessed urrder IC 61. 7-7 or manufectured homes rrot assessed as real property: u)f�e'M1Wttr4-b72/ months
beloreMarrh37o/Neyearfhetletluctionisfo6eeHective. GIBSONCOUNTY UDITOR
See reverse sWe 7a atlddronal insbucfions end oualificalions.
Typa W beneH (epua (please rliock e0 Net appl� /
er 65 Deduction from Assessed Valuation /L�C�ver 65 Circuit Breaker Credit
i — �
NameafaOMKa (owriu'or�aR+
his/ner e' share w interest7 H owned �vih someone other than spouse.
' indi�te with wnom
❑ Yes ❑ No
H name on racord'u diflerarit than Nat of apdicant, IrWkate bebw
tiame oi eoncraa se�ier (aanrranf must naee beon buy'ug on eanvaa et �ees oire (1) yeep -
� lddreas of mntratl m�er (numOwaMabeeG ciy. slate. and LP co0e) Is iha p(ooefty in auestiw:: _
Real property � Mobile home (IC 67-7-�
Tazing ' d Key be� l�a/aJ�acnpyojl� �j/J o RS��d number Page number
/ / L'3C.CJ ✓i 7 /
U we omoeM �� ar�e «a,aea mariy br Assessad valua ot ltre popeM as ot March 1, curtert year (may rrof axceed Sf82,d30
FdaTher residenm7 !or Orer 65 deducfian, a 5760.000 fir tlre Ovor 65 CtictiR &oakw Cradi�
� Yes ❑ No
Wa� the a0W��7 65 yeen of age w mora on December 31 of t�e year Ap0licanfs data of birth (rtronth, day. yeaQ If (led by a surviv'vi8. unmamed spouse,
prior to the airtertl yeaR wha� was the spouse's aga zt the time
❑ Yes ❑ No o�dean7
AdJusted gross ineome of appliwnR BPouse, and any
Have you filed for a�ry other deducGms7 IfYes, whai deductions7
� Yes � NO �
Have you fled for CeEUCtiona in anY �er coumy? 111§s. what couMy?
�Yes ❑No
IlWe certify under penalty of perjury that ihe above and foregoing information is Irue and correct and that the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20 _ � �
Sign ure of a rtl rass of aoplibnt (numbor aM sboet, ciry, stala. aM ZIP coEe)
(
G� �- �-% �` C N Y N L{ %b 7(7
pnatura of a an reore�errtatrva Mdress of aNhonzad rewasentative (numbwantl s;reef. ciry, sfato. anG ZIP cotlo)