Age_Williams� APPLICATION FOR SENIOR CITIZEN couNn � TOWNSHIP � YEAR i
e PROPERTY TAX BENEFITS
` ! Sbte Fortn 43708 (R919-OB) �
� P(awibed by Ihe Deoartmarit of Local Govamment Finance �
il Ma k �
Irfortnation containetl in this document is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-7.1-35-9.
wsrRUCnoNS DEC 2 9 Z008
To 6e filed in persan or by mail with the CouMyAUditor o/tfie county where the properfy is located.
Filirg Dafes: 7J Real Property: Dunrn� the hveNe (72) months be/ove December 37 o/fhe year fhe deduction is to 6e eHect�" y� /�
2) Mobile Hanes assessed arrder IC &1.1-7 ormanulactured hdnes no( assessed es real pmperty: Dunng th�IMe�16A'f72fin�i�it�l�cs
berore March Jf o7tne yeartne deducaon is ro be e%ctive. G�gSON COUNTY Au�7� ��k
See reverse side (or adddional insWdions end qualificaGons.
Type d beneH rapuaSfeE (ploase dreck a➢ Nat app�
QSJ Over 65 Deduction 6om Assessed Valuation �Over 65 Circuit Breaker Credit
Name of aDd�M (� acont2cf 6�yeh • ,
Glf� � /��/ih'/�S
Is ao0fimm the sole leyal or epuitaWe owneR If No. what is :JSlher exact share o: intarest7
Yes ❑ No
It nama an racord is diflarem lhan ihat of apdifant ��dicate bebw �
Name of mntad seller (apWicant musf hava Deen Duying on conlacl af /east ono (i) yearj
Address ol contratl saller (number aM sbeet, ciy, sWto, end Z/P code)
'/
Is iha propeM used and oicupied�nmaNy br
hivhar resideno7
�Yes ❑ No
Was iha aOW��m 65 years of aga o� mwe on December 31 ot ihe yaar
o�or to Ihe arrent yeaR
Yes ❑ No
Adjusted gross income of appliwnt, spouse, and any
individuals sharing ownership (FOrOver 65 deducfion, income
may not exceed 525,000; for the Over 65 Circuit 82aker C�edit,
income may not exceed 530,000 for individuals, or 540.000 for
martied couples).
you (Jad tw any Wher deduc6onsT
Mave you fded tw
� Yes
any mher counry?
� Yes
� No
� No
I�ryNlIBdWIIi $O.T.BOfiB
'v.�ipte witn w :om
o�ooerty in Cuastion:
soouse,
I� Real property � Mobile home (IC 644-7)
' � / • �R�tlQmS�rO� � Page numbar
�%
Assessed value of t"e o�oerty as of Marct 1, wrtem yaar (may rroc ercectl 5782,a3G
tor Owr 65 tlotluaion, or 5160.000 lor:ne Over 65 Ciicuil &uaker CreOi�
Aoo����1's date of birin (monih, day, year) It hied �y a surviving, unmametl spouse,
what was Ihe soouse's age at the time
� /
of Income � Amount of Income
�
$�
IIVJe certify under penalty of perjury that the above and foregoing information is true and correct and lhat the applicant was a resident
of Indiana and owner of the a(orementioned property on March 1, 20 _
Sgn reoiaGWicapl AEd2ssafaDDlicar.t (numDdanCSfroot,ci.y,stafe.andZlPCOCe)
/L n �J /
% / / / ��� � ��S � �� ���P
Sipnature o(avNOnzed reore5enlaVVa ACEress of authorizeC reoresentativa (numberantl sueel. ci.y, sate, and LP code)