HomeMy WebLinkAboutAge_Vickers (3)APPLICATION FOR SENIOR CITIZEN courrrr TOWNSHIP r�aa
_ PROPERTY TAX BENEFITS
• . ' . � Stala Fwm 43708 (R9 / 408)
•� � Prescnbad by Iha Dapartmenl of Local Govemmerit Finance
� Informatiom m�tainetl in this doaiment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC G1.1-3r9.
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INSTRUCTIONS:
MAY 7 2012
To 6e filed in person or by mail wifh fhe CountyAUdita of fhe munty where tl�e property is locafed. �
Filing Dates: 1 J Real Property: Dunng the hvehre (12J mrnths 6e/ore December 37 0/ the year the tleduction is to be eRe�cGvernP����
2J Mo6ile Hwnes assessed urMer fC G7.1-7 or manulactured homes irot assessed as real property: Dunn9 fhe N+e 7 fhs
befora March 37 otthe year Ihe deducbon is to 6e efFective. GIBSON COUNTY AUDITOR
See Iaverse side hr adddional insWC(ions arM qualifiwtions
Type d benaH raquested (please di a0 Naf appy)
er 65 Deduclion 6om Assessed Valuation Over 65 Circuil Breaker Credit
Nameofap (owrre�ocanhadboyerJ ,
Is app nl tha sole lepal o Q itaWe (7 If No, whal is hisRle! ezad share w inleres1l If avmed wfth mmeone Wher than spoum,
indi�ata with whom
es ❑ No
If name m racord is ddferent Ihan tlut W applirant, iMkate bebw
Name m can,aa sener (apar¢snf must nave aeen ouyiig a, ca,rract at roast orre /7) yearJ
Adtlrass aP mntrad w0ef (number aM streeC �: sblu. arid LP mde) Is Ure PmPeM in 9uestbn:
� Real pmperty � Mobile hame QG 67-0-�
Tazing distrid Key number / Lagal desrnption Record num6ar Page number
� h I
Ls Ihe pmperty used aM occupied primarily br Assessed value o( tha property az ot Ma�ch 7, wReM yaar (may irot exceetl SiB2.a30
hisrhar rasidenwY IurO�er 65 dedudion, or 5160,000 PorNe O�.er 65 Circu! &ealmr CmdiQ
❑ Yes ❑ No
Was �ha appGaM 65 years of aga w rtwre on OecBmber 37 of �he year Applitam's tlate of birth (rtwnN, day, yra� Iflled by a surviving, unrtefried spousa,
prior lo Na airtem yeaR �Mat was tha sqwm'e age al the t'une
❑ Yes ❑ No oraaam?
Adjusted gross income of applitant, spouse, and any
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� Yes � No
Have you (li ed tor deductiona in any mher munry7 If Yes, what courrty7
❑ Yes ❑ No
IIVJe certity under penalry of perjury that the above and foregoing infortnation is true and wrrect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March i, 20 _
Signatu aP7�M AtldressofapP�nt (monbalerMS eL te.and���odu)
�l� e�'�- 3 a s: � s,.-
.� y
gnature d aWhon �ep entalive tltess of aNhorimE �ap�esentative ( unDer arrd sl�eet, cify, slat0. enC LP code)