Age_McEllhiney'����APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
Sbte Form 43708 (R9 / 9-08)
PrescnbeE by ihe Depariman� of Locai Govammem Finance
Infortnatbn tontained in this doamen, is CONFIDENTIAL Dursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
INSTRUCTIONS:
COUNTY TOWNSHIP � YEAR
File �
To 6e filed in person or by mail wdh fhe CountyAUditw ol (he county whera the pioperry is locatetl. DE � 1 O c008
Filiry Dates: 7J Real Property: Ounng the fweNe (72) mw�ths 6efore December 37 olfhe year iha tletluction is to be/-sy/f�ecfive.
2J MobHe Hanes assessed urrdei IC 64.1-7 or manWactured homes nof assessed es real pmperry: �GRA§+i4e tu�ly4,�{22) months
belae March 37 0l fhe yeai the dsduc6on is to be eHactive. GIBSON C0� TY ✓
See reverse sitle !w atlddional InsWGions arrd qualifications. A UCiTOq
Type d benefl reQUeSfaE (Waasa rhack a0 thaf apd�
�er 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of a0W��1(owner or cartracf Duye� •
� � ��
Is aoolksm tha sde legal or eouitable ownen tl No, ..at is nis�Ter ezaa sna:e or intarest9 If owneC witrt sameona othar ihan soouse,
ir.dinte with vn. om
❑ Yes ❑ No
It name on record is diflarent Ihan ihat of aodican� indicate balow
Name af mnl2ci 6etler (apWicanf must have Eeen Ouyirg on conLact al basf one (iJ yeaQ
� Addrass W mntrad ee�er (numDeraM sbee4 �y. sb(e, aM ZlPcode) �s tie omoerty in cuestion:
� Real propery � Mobile home (IC 6-1-7-�
' g disind Key number / Legal descnotion I Record number Paga numuer
o��. �6-! -IS• OD-DO�l.o�59-��
Is ihe �opaM1y useE arM occu0. O orimanN kr Assessed value of t"e omoe:ry as of Ma¢h 1, wRen� year (may nof erceed S1ffi.a30
hislher iesideno? tor Owr 65 tlotluaion. w S f fi0.000 !or tha Over 65 Ciicurt Bmaker Credi!)
❑ Yes ❑ No
Was the a0�m 65 years of aga or mwe or. Decembar 31 of the year A�olimnfs date of birth (mm:h, tlay. yoarJ I( filec by a survivlr.g, unmamed sxuse, I
o��orto tha artem yeal) whai was ihe soouse's aSe at lha time
� Y85 ❑ NO otGeatn?
Adjusted gross income of applicanR sPouse, and any �
Have yoa (dad tor eny other detluGbnsl If Ws, wnat aeductions?
� Yes � No
Hava you (Jad Iw deCUCtions in any ather counry7 I('ks, wnat counry?
� Yes ❑ No
I/We certi(y under penalty of perjury that the above and foregoing information is true and correct and ihal the applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20 _ .
� gg��� AEdrass ot a�olimrt (numberantl sheef, ci.y, sfate. and ZIP code)
' � r ✓ a s -W e 0✓� %�
' natu d authonzetl �aD e a a PACrass of authwizac ra��asentative (numGeranC s:leet. ciry, .taro, antl ZIP tode)
� ,.