Age_Price�l
�� "a APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
� • .' _ Sfate Fortn 43708 (R9 / 9-08)
•O ! Presuibed by Ne DapaNnenf ol Loral Govemment Finance
�� Information containetl in this doaiment is CONFIDENTIAL pursuanl to IC 6-1.7-12-9 and IC 61.135-9.
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wsrnucnoNS:
COUNTY TOWNSHIP YEAR
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APR 1 6 2012
To 6e filetl in person or by mail with fhe CourrtyAuditor ollhe county where the property is located. ^
Filirry Dates: i) Real Properfy.� Dunng Ihe tweNe (72J mmths 6efore Decem6er 31 o/the year (he deduc6on is�"U6�
2) Mohile Nanes assessed under IC fi1.7-7 or manulactured homes rrot assessed as rea/ piopeM� Dunng th (72) monfhs
be/we Marrh 37 of fhe year the deducfion is fo be eRective. G�BSON COUNTY q�Jp�TOR
See reverse side tor atldi6onal insWdions arM qual'dications
Type d beneft repue5ed ease dieck aD IAat appiy)
�Over 65 Deduction from Assessed Valuation �Over 65 Circuit Breaker Credit
Name of ap licam (ownor w cmlydcf buye� /�
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Is app&am the mle lepal or equitaGe awneR H No, what a his/her exad share a inlerest? If owned vnU somamie other ihan spouse,
indimte wi�h wtmm
❑ Yes ❑ No
1( name on rawd is diflarerif than that ot a0d�nt indicate bebw
Nartre af cwrtraG se0er (appllcant musf Azve been buy"ug m canllact at leasf oire (1f yoaQ
Addfass of mntratl mller (num6e� aM sbaef, cify, sfale, aiM LP wde) �s lhe pmPeny in Quesiion:
Real pmperty � Mobile home (IC 6-7-1-n
Tazing d'atrir]
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Is �he pmperry useE a�k occupieE O�ariy Ior 0.ssessed value ot the property as of MafcA 7, curtent year (may rwt a+cer.d 5782,430
hisiher rasidance7 !or O�er 65 deduct:m, or 5160,000 for Ne Wai 65 Ciicuit Broelmr Credi�
�Yes ❑No
Was the appfran165 years ot age v mora on Oecember 31 0! 1he yaar
Mave you filad tar a�ry other deductians? tl Ves, what deductions9
� Yes ❑ No !T' S '
Have yau fded ta deductio(ss in any other counry? It Ws, what cwmyT
� Yes ❑ No
IIWe certify under penalty of perjury fhat the above and foregoing information is We and correct and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signature d a pfuant AdCress of appfimnt (nunOrlanO sboof, tity, stale, aMZlPCOda)
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Signa ure W auNOnzetl represantative AEdress of au 'zed rapra ntaY (num arid sfrect, nty, sfafo, and P codo)