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�"v APPLICATION FOR SENIOR CITIZEN couNn TOWNSHIP r�
:� -. PROPERTY TAX BENEFITS
��f• StateFortn43708(R9/9-08)
PrasaibeE by the DeparimeM of Lacal Govemment Fnance
Informatiom m�tained in lhis doament is CONFIDENTIAL pursuanl to IC 6-1.1-12-9 and I�Q-1�358. �� File Mark
/NSTftUCTlONS: � gJ
To 6e filed in person or 6y mail with fhe CountyAuditor ol the wunty whera fhe property is IocatpF{.� � ���
Filing Dates: 1) Real Properfy.� During Ihe hveNe (12) mmths before December3l o/the ya� e educ to be eflectirvs.
2) Mobile Homes assessed urMer IC 61.1-7 or manu7actured homes rrof auessed as �Qroperty: Dunrg Ihe hvelve (12J monfis
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befoia March 37 of the year tlte tleduction is fo be e/fective.
See �everse side fw additional insWdions arM qualifications �
GIBSO T
Type of heneft requeged (please rhec4a0 fhaf appl�
� Over 65 Deduction 6om Assessed Valuation ❑ Over 65 Circuit 8reaker Credit
Name of app&aM (oumex a cmtractyyye�
Is appl�rrt lhe sda lagal or aq�itabla owneR
�Yes ❑ No
H name m racrord is diRe�ent than tlut of apqicant, i`Micate
Name o( cantrad v
� Pddresso(mntraU
pplmanf must have been buyirg m cantrdG a
(n� er aM stree4 UY, slafe. aM ZIP cotle)
T
orre
Key number / Legal desaiplion
Is �he G�KY used aM occ�pieC primaNl' br
hivhar residenm?
�Yes ❑ No
Was tha app6rar�t 65 years of age or more on Oecember 31 of ihe year
o�or ro ma a,rrem yean
� Yes ❑ No
Adjusted gross income of appliwnt, spouse, and any
individuals sharing ownership (ForOve�65 deduction, income
may not exceed 525,000; for the Over 65 Circuit 62akerCredit,
income may rrot exceed 530,000 forindividuals, or 540,000 for
married couples).
Have you fded for aery other dedumwis7
� Yes
you 13ed ta deduaions in any dhw muMy?
❑ Yes
w interest7
tt ovmetl with somawie olher than spouse.
indimte with whom
> P�M in auastron:
� Real property � Mobile homa (!C 6-7-1-�
Remrd num6ar Page numbar
��-c�o L�4� - bD�i I
Assessed valua o( Ne property as ot March t, wneM year (may iwf exraetl 5182.030
fw O�er 65 deduCbn, w 5160,000lo�Ne O�er 65 Cbaif Breaker CreEiQ
:
1lWe certify under penalty of perjury that lhe above and foregoing infortnation is true and correct and that the applicant was a resident
� of Indiana and owner of fhe aforementioned property on March 1, 20 .
siqna�ur� d app'�m nddress of avv�m (n�anber and stree( uly, s7ate, and LP mde)
u �?� �
.5 . S , :3 s �J �
Signature d authaized reprasantadve Addass of aiehorized represenfative (numbeiarM sheel, nty, ate, an LPcode) /__[�1/ 2
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