Age_Mauck"' A APPLICATION FOR SENIOR CITIZEN
r .- , PROPERTY TAX BENEFITS
Spte Fwm 43708 (R9l 9-OB)
� S��u � PrascAbed by the Departmerit of Local Govemmem Finance
Infwmation wntalned In Ihis Cocument Is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
INSTRUCT10N5:
COUNN � TOWNSHIP � YEAR
APR 1• 4 ZUtU
To 6e Rletl in persm or by mail with fhe CountyAuditor o/ the oounty where Ihe properry is locatetl.
Fill� Dates: 1) Real Prvperty.� Dunrg the M1veNe (12) marths 6efwe December 37 0/ the year the deduction is to 6e � .
2J Mo6ile Homes assessed under IC G7.7-7 or manufactured hanes rwt asseued as real property: Dunrrg w�iveAre�monws
6e/ore Mardr 37 0l fhe year the tletluc5on is �0 6e elfective. QIBSON COUNTY AUDITOR
See reverse side lw edddional lnsWUions arM qualifications.
Type of beneft reQUesSeO �pleate tlixk a➢Naf appy)
Over 65 Deduciion 6om Assessed Valuation � Over 65 Circuit Breaker Credit
Name of aDG�wni (Owner n' cantred DuyeQ /,
. � ��iu"i✓—
Is a0o. m a sde lepal or eQUitade ovme�l tt No, what u hisRier ezea s�are or inta:est? If owned w�lh swneme olher than sDOUSe,
indi�ate with wtrom
❑ Yes ❑ No
tt name on recortf is diflereM I�an that of epDlicant, iMiwte 6elow
Nzme m comae sener (ean'�Kent mus� nave oeen euymp a� canvac� e� roasr or�e (�) r�7
fddress W contrad sellar (num0er a�d abeet, ciy, state, and ZIP cotle) �s lhe o�Derty in puesiron:
Real property � Mobile home (IC 6-7-7-n
� Tuing disiriq Key number I leqal descnWion Record numbar Paga number
.00�. .T� 6a�
Is ihe o�PeM useO aM occupad wimany br Assessed value ot the WoDeM as of Ma¢h 7, wrtam year (may rrof erceotl 5182,d30
hisRier residance7 !w O�er 65 deducfian, or 4760.000 lor No Ovor 65 Circuit &eaker Credi�
Yes ❑ No
Was the aoW��165 yeara o(ape or rtare on Dacember 37 ot ihe year
Have you filed for any dher de0uc0ons� �t Ves, what deductions?
� Yes � No
Have you fled tor Eaductions in eny Uher cwnry? tl W s, what wunry7
❑ Yes ❑ No
IlVJe certify under penalty of perjury that the above and foregoing information is We and cortect and that the appiicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20
Signature e�prraM Addte950}eDO�ifdtt� (trtuPDCldIX1Sb�Oi.Cify,ffif0.0MZ1 �)
�.%0 L £� � V � � o .� . -.
iqnature W authauzed rao�asenta e'� Address of euthonzad reo�esenWtive (number a� stioo�, ciry. sfafo, and ZlPcode).