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APPLICATION FOR SENIOR CITIZEN couNrv I TOWNSHIP I YEAR i
� PROPERTY TAX BENEFITS
� ` ! State Form d3708 (R9I408)
Prescnbed by ihe DepaNnenf of loral Govammant Finance
File Mark
Infwmetion contained in t�is tlocument is CONFIDENTIAL pursuant to IC 6-i J-12-9 and IC 6-1.1-35-9. ��"'�
To be filed in persm or by mail with fhe CountyAuditw ol the county where the property is /ocated. ��� A�
Filing Dates: 1) Real Property: Dunig fhe fwelve (72) monfAs be(ae Decem6er 3f o7lhe year the deduction is tq�a§trvl4 �(1n S
2) Mobife Hanes assessed under IC 6-7.1-7 or manufacturetl homes nof assessed as real pmperi� ng�rire twaYireu (72J months
be%re Merch 31 o/fhe year the tleduc6on is l0 6e effective. �/
See reverse side la edddional insVUdions arM qualificafions. ���J%.,, �v �
�
Type d
Name
11 name on
(doase Meck a0 uwt appy)
65 Deduction from Assessed Valuation
caih^actEUye�
/l C
f
sde lapal or eCUilaWe owneR
❑ Yes ❑ No I
N is diflarent Ihan Nat of a�dicani, iMicate below
o( contaa seller (applicant musf Azw Oeon buying m contracf
P4dress of mntraG
crly, stafe, aM ZIP cotle)
b Ne D�GeM used aM occuped orimany br
�islAerresidencel
Yes ❑ No
Was the apWkan165 yean of aga or mora on Oecember 37 of the year
prior to the anem yea(7
� Yes ❑ No
GIgSON COUNTY AUOnv�
�Over 65 Circuit Breaker Credil
l
�-+/Vl�./ �
share w interast7 If owneC with wmeone other ihan soouse.
indinte vnih wFwm
ono (7) yea�
Adjusted gross income of applicant, spouse, and any
individuals sharing ownership (FOr Over 65 deduction, income
may not exceed 525,000; lor fhe Over 65 Circuit 8reaker Credit,
income may not exceed 530,000 !or individuals, or 340,000 for
married couples).
Have you FJed for arry Wher deducCOns7
Hava you filed tm Oeductions in any ocher
� Yes � No
�
� Yes ❑ No
f-,�/Do7- OQ/.
D/OPeRy in cuesti0n:
Real property � Mobile home (IC 6-74-�
Record num r Page number
�- �G�
Assessed valua of the pmoerty as of Ma¢n t, cunent year (may nof exceed 5182.430
far O�er 65 deCUIXian, w 5 f 60.000 for Ma Ovor 65 Circ�it &cake� Credi,)
IIWe ceAi(y under penalty of perjury thal the above and (oregoing information is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
W epplicam
� �2 GJa�a.�.��-�J
�epresentative
ACEress of a001irent �(n/um'0erantl sVCOf, ciry, staTro, and ZIP rotle) /�
• � �Q NO%�f( �R"r�lJJJ12� (?Ti �KGi�uR7 l:I�� //�%
Adtlrass of au�norized raorasentative (numEeiaM sbea:, ci.y, xatc, an0 Z/P cotle)