Age_GrayAPPLICATION FOR SENIOR CITIZEN couNn TOWNSHIP reaa
PROPERTY TAX BENEFITS
, ', • State Fortn 43708 (R9 / 9-0B)
� Prescnbad by ihe DeoafLmeM af Local Govemmem Finarrce
File Mark
Infwmatiom m�tained in this document is CONFIDENTIAL pursuant to IC E1.1-12-9 and IC Fr1.135-9. ���� w
A tl
INSTRUCTIONS:
To be filed in persm or by mall wifh the CountyAUdi(or o! the munty where the properry is Ixated. �Lj
Filirrg Dates: 7) Reel Pioperty: Dunng the tweAre (72) mwiths 6e/ae Dewmber 37 o!(he year the tleduction is to b�f�rJ'���
2) Mobile Hames assessed under IC &7.7-7 ormanulacfured homes rro( assessed as real propeRy: n'gTfh onths
befwe MarM 37 0/ Ihe year the deduction is to 6e etFecGVe.
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See reverse side 7or additional InsLUGions antl qualifica(ims. � �
a
ryoedtenectrecues+ed(�+ease xac�nata� GIBSON COUNTY AUDITOR
Over 65 Deduction from Assessed Valuation ]� Wer 65 Circuil Breaker Credit
Nameo(apdiwnt ovmeratonbacfbuyo�-�
le aoolimm tna sda lepal or eQUitaW aR tl No. wfiat is hisrh ez d sF.are or intaresl7 H owned wiih someone dter Ihan soouse.
'vMimte wiih whom
Yes ❑ No
H name on record is difFerant Nan that oi apolifan� indiwte balrnv
Name ot cartta seller (app!'rcanf musl hare Leon buyinp wn con:raa af leasf orro (1) yearJ
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Address of mn d seAer (numbw aM sbeef, cify, sfate, arW ZIP code) Is �he p�o�etty in uuastion:
� Real property � Mobile homa (IC 67-1-�
Tazing distnct Kay number / Legal descriotion Record numDer Page rumDer
2,Cv-� y-�9-�oa-000. -cao
Is Ne Dmoerty used end occupied onmanly br Assessed value of the propa�ty as ot March 7, wrrent year (may rrof axmaC 5;82,a30
hislnar residanca7 roi O�er 65 tletlurlim, m 5760.000 !or Ne Oirer 65 Circtct Broakar CrediQ
�� es ❑ No
Was ihe apo�Ken165 yeers of aga or rtrore on Decembar 31 of Me year
r�e y«, nad �« a�,y anar ead�,:v If Vea, wlwt deduCior.s?
� Yes �No
Hava yo� fded tw deduc6ons in any other counry? If Tgs. what courtry?
� Y05 0
I/VJe certify under penalty of perjury lhat the above and foregoing information is frue and correct and that the applicant was a resident
of Indiana and ownar of the aforementioned property on March 1. 20 _
Signeture af appGCarrt Address of applibnt (nunba eiMsbael, cily, sfete, aM ZIP wde)
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Signature of euthonzed reo�esentaiiva PdOrasa oF aNhorized rev�asentative (numberend sLeef, ci . 9afo, and LP code)
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