Age_Longabaughv
., „"`"o APPLICATION FOR SENIOR CITIZEN
� PROPERTY TAX BENEFITS
State Form 43708 (R919-OB)
� � PeewibaE by ihe DeparimeM ot Loml GovammeM Flnance
� Infortnation contained in this do�ument is CONFlDENTIAL pursuant to IC 6-1.1-12-9 antl IC 6-1.1-35-9.
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INSTRUCTIONS:
Tobenedinpersonor6ymailwiththeCountyAUddorolthecountywherefhepropertyislocatea. A�R , a ZD�Z
Filirn� Dates: i) Real PropeRy: Ounng the hveNe (72J mmths 6e/ore Decem6er 31 0/ the yea� the derlucfion is to be effective.
2) Mobile Hanes assessed under IC bt b7 or manWactured homes rrot assessed as real pmperty.� Duri� „�B� ths
6e�ore Maicft 31 0! fhe year the deduction is to 6e eRecWe.
See reverse side taredditional insLUCtions and qualifications GIBSON COUNTY AUDITOR
TYPe d benaf.t repuesied (please diock aID that aPpl�
�er 65 Deduction from Assessed Valuation er 65 Circuil Breaker Credit
Name of aPd�M (owne! w conbact buye� /�
1/
� \Y
Is appfxam the sde lepal or ' e . share w interest If wilh srnneone other lhan spoum,
i e with wbm
❑ No
H �ame on rewd'u E' nt Ihan Uat d applifant ��dkate beb.v
Na�re of cwrt`aa sener (aaW+��� m� nave neen nyvg o, cmt�-dC af leas ona (11 r�l
Address d mntrar, mller (number aid stree4 �A'. slale. ard LP code) Is the proparry in 9uestian:
� Real pmperty � Mobile home (IC &7-7-�
Tazing Eatrict Key numbar / Legal dasrlipibn Record number Page number
t� -pa-a ,
I5 �ha propeM ��W� P^�M' �r Assessed vaNe ot ihe qoperry ot March i, curterit year (may mf eroeotl f 782,430
hivher residan lorO�er 65 EeduCim. ar E760.000loi Ne Ovei 65 Circu'rf Breelai CrediQ
❑Yes ❑No
Was the appli�aM 65 years of age ar mora on December 3 Ua year
r�a rW �ad io. am anar em�,mor�:t if �. �� eae�m�?
❑ Yes � No
Hava you fJed for deductions in any Wher cwrrty7 If 14s, whal tounty?
❑ Yes ❑ No
IIWe certify under penalty of peryury lhal lhe above and foregoing in(ortnation is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signatura d eppfcant Address of aDDli�ant (num0erandstmef, dty, s1aW. arid ZIP oode)
Si at daul�mizadreP���a�^'e Addresso(au�hor�drepresenlative (numbrlarWSboef.city,sfafe,andLPmde)