Age_Kiser�
� APPLICATION FOR SENIOR CITIZEN couNrv TOWNSHIP vena
PROPERTY TAX BENEFITS
S '• State Fwm 43708 (R9 / 9-0B)
Prescn6ed hy the Department of Lacal Govemmam Finance
,I � F a
Infomiatbm m�tained in lhis Cocvment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.7-35-9.
rNSraucnoNS: O C T O 1 Z O 1 O
To be filetlln person or by mail with fhe CountyAuditorol fhe oounty where fhe property is located.
Filirrg Dates: 7) Reel PropeRy: Ouri� fhe tweNe (72) monfhs 6efore Decem6er 37 0/ the year the deduction is to be eHective.
�
2) Mo6ile Hwnes assessed urMei IC 6-7.1-7 or manufectured homes rrot assessed as real properiy�n`Dy,�th�f2) monlhs
befae Mardr 37 0/ the year the deduction is fo 6e eflactive. Q
SeeieversesiCefaatltltionallnsWdionsentlqualificaUons. GIBSON COUNTY AUDITOR
�
Type d henePo recuested (ploaso d�ocka0 Naf epp�
Over 65 Deduction trom Assessed ValuaGon_
Nama of aDd��i (ownai n' canpn(t DuyeQ , �
sale Iegal
Yes ❑ No
If No, what is F+sf�er eaact share
H name on retortl is 7iflarem Nan that o( eod��l inEicate 6elow
Nama d canirad
Is U�e O�OeM useC arW
his/her reSiEen�T
m cmLact at least or�e i�) Y��
and sbeet. ciy, slab, aM ZIP coCe)
Key number I Legal
Yes ❑ No
Was ihe aOMKarit fi5 years of ape a mue on December 31 of lh year
' o�� to the artant yean
s ❑ No
Adjusted gross income of appliwnt, spouse, and any
individuals sharing ownership (FOr Over 65 deduction, income
may nof exceed $25, 000; /or the Ove� 65 Circuit Bieaker Credit,
income may not exceed $30,000 for individuals, or 540,000 foi
married couples).
Have you (led fw aery other Oeductbns7
��o No
Hava you (Jed fw deCudions in any other cwmy?
� Yes ❑ No
.�er 65 Circuit Breaker Credii
i someone other ihan spousa,
whom
Is the pmoerry in Question:
�Beayroperty ❑ Mobile home (IC G74-n
i RecoM numbar Page number
��4o3-�bo= �-�-�o
AssessedvalueottheDroDertyasTMaah i,currenlyaar(may�rotorteed57H2.a30
ror o�e. sa aoauaion. or siso.000 lor ure ow. ss cirt..iif aeaker creai�
Appli�anfs date o( birth (mmth, day, yea� If (led by a survidng. unmarried soouse,
what was the spouse's age at iha 6me
,� _ � � of deaLh?
If Yes, what deductions?
If Yes, what
Amount oi Income
5 ��
IS
TOTAL I S 0.00
IIVJe certify under penalty of peryury lhat ihe above and foregoing infortnation is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1. 20 _
Addeess of applirent (number antlSWOf, cty state. aM Z/P code)
�D I� 4 S� Ga vn � be� I I� I �/�1 _
A�ddress of aulhonzad reo�esentative (numba� a sbeef, ciry, state, antl LP code)
���