Age_Marvell= APPLICATION FOR SENIOR CITIZEN
. � PROPERTY TAX BENEFiTS
� S .. -' State Fortn 43708 (R919-0B)
Prescnbed by the DaoartmeM ol Local Govemmem Finance
Infwmatiom m�tained in Ihis docvment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC frt.i-35-9.
/
f
COUNTY TOWNSHIP � YEAR
File Mark
��� �
.�
INSTRUC710N5: �
To ba filetl in person or by mail with the CountyAutlifor o/ the munry where the property is located. gJ
Filirg Dafes: 7) Real P�operty: Dunng the fweNe (72J months be/ore Decem6er 37 o/the ysar the deduction is to be p p
2) Mobile Hanes assessed under IC 6-7.1-7 ormanulacturetl hwnes rrot assessetl as real property: Dun e N+elbe��j ii�onths
be/ore Marrh 31 of the year fhe deduc6on is to be eRec6ve.
See reverse side /a addifionsl instniUions end pualifications. �� ��
TypBWbenef�repuea�etl�(pleasedittke0lhatapply) / GIBSONrni�.�.., ��_.
� Over 65 Deduction 6om Assessed Valuation j`�J Over 65 Circuit Breaker Credit
/
Nama /of'�avdka�t (m�ner a tonvad Duye�
�-�.t.KCC�iJ (J��!/U'�-�1
is aooi�mm tne sde iepai or ec�naae ownen I( No, w�et is his/tier exact share w interest? tl o.vned with someane
indiCate wi�h wlrom
❑ Yes ❑ No
name on:acord is diflareM Nan thal d eppfrsn� i'Wiwle babw
Name af coni2cl seller (appicant musf have Oeon
ciy, afafe. eM ZIP co0e)
yea�
Kay number I Legal descnotion
I5 the pmpeM used eM attupied primanly br
hiaTher residanm7
❑ Yes ❑ No
Was lhe aOM�m 65 yaen ot aqe a more on December 31 of �he year
prior to ihe arrem yean
� Yes ❑ No
Adjusted gross income of appliwnR BPouse, and any
individuals sharing ownership (ForOver 65 deduction, income
may not exceed 525,000; for Ihe Over 65 Circuit 8reaker Credif,
income may not exceed 530,000 fo� individuals, or 540.000 for
mamed couples).
Have you filed M arry dhar tleCUCtims7
� Yes � No
Have you filad tw deductions in any other courrty7
� Yes ❑ No
soouse,
the pmoer�y ln QueSlan:
� Real property � Mobile home (IC 6-74-�
RecoM number Page num6ar
0.ssasseE vaNe ol the prooerty as of MaR7i 1.
!or O.er 65 datluCion, m 5760,000 Ior Na On
IIWe certify under penalty of perjury that the above and foregoing in(ormation is trve and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
anetura ot aodkem P.dd�ess ot eppti�nt (numEorantl stroet, city, siate, aM Z/P codo) n
' ' i3r�Q�Y
�/�.�
Signatura cf authonzeO reD�sertlativa
oi aNtwrizad reweseniatrve (num0el aM sux; ciry, sfafo, and