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,PPLICATION FOR SENIOR CITIZEN courm TOWNSHIP v�aa
ROPERTY TAX BENEFITS
ate Fartn 43708 (R9l 9-08)
awibed by Ne Departmam ot Loral Govemmenl Finarrcs
i18 ark .
Informatiom m�fained in this dowmenl is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 61.135
INSTHUCTIONS:
To be filed in person or 6y mail w"ith the CountyAUAifw o1(he munty whare the propeAy is located. � A N 1 0 2 Q � 2
Filing Dates: 7J Real Property: Dunng fhe fweNe (12) mmths 6e/ore December3l o7the year fhe tledu¢tion�i�.fp� �.
2) Mobile Hanes assessed urMer IC Fi1.7-7 ormanulacturad homes rrof assessetl as rea/ property: DunRg the\hvelve (72J monfhs
6elaeMarrh37oftheyearthedeductionistobeeAecWe. GIBSONCOUNT AUDITOR
C.�n.� �oirinl�ieAilAi��nli�Nr��rlinn erMn�ia/ifiralM
Type d beneft repuasled (p/oase a0lhat apply)
er 65 Deduclion 6om Assessed Valuation Over 65 Circuit Breaker Credit
Name of app6raM (ownvr w cnitlad GryarJ
b app&am Ihe sale legal or equi eR I( No, what is his/nar asaU sh iriterest7 H ametl wBh mmeone other ihan spoum,
iMitate wiih whom
Yes ❑ No
If name on recoN is Ei(ferent than Ihat of apqiranl iMkste below
Nama d cont2c] seller (app(manf must have been buyirg m cmhacf af /easl orre (1) yeaiJ
Pddress o( mntraU w0er (number aM sbee4 �+ry. shle, and LP wde) Is the pmpeM � auestion:
� Real pmperry ❑ Mobile homa (IC 67J-�
Yxing d'aitiG � Key number / Lepal dasuiption Recortl numher Page number
���F a6- -� - 000. 3� ��o aa
Is fhe pmpeM used and xapietl primardy (or Assessed value o( lhe property as oi Marrh 1, wRent year (may imf nxceotl f182,430
hisTher rasidanml toi O�er 65 detl�dim, � 5760,000 for Ne Over 65 Cucwf Breafnx Gedi�
❑ Yes ❑ No
VJas ihe app6raM 65 years of aga w rtore an Dacamber 31 year
whatwasthespousa'eapeatihetime
ot eeath7
es ❑ No
Adjusted gross income of appliwnt, spouse, and any Source ot Inwme Amourrt of �ncome
individuals sharing ownership (ForOve� 65 deduction, income $�—�
may not exceed 525,000; (or the Over 65 Circuit 82aker Credif,
income may not exceed %30,000 for individuals, or 540,000 for $
married couples).
TOTAL $ 0.00
Mave you tled tor any aher tletlucUOns? H 1bs, what dedudmrm?
es � No
Have yvu (Jatl for tleductiore in anY oLher caunty7 H 14a. what mur�ty7
❑ Yes ❑ No
IIWe certify under penalty of perjury lhat fhe above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signaluredappl'cant Pdtlrassofapplimnl (numberaMStroeGaty,sfale,arMZlPCade)
,
g daulhon edre esentativa Ptldress f ulhorizeErapresentative (numbuarxlsLOaf.city,state,andLPCade)