Age_FryeA
� APPLICATION FOR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
, � Sta� Form 43708 (RB / 9-08)
� P'asuibed Fry the DepaMmanl of Local Govemmem Finance
I�ormation oontainetl in Nis tlowmenl is CONFIDENTIAL pursuanl to IC G7 J-12-9 and IC 6-1.1-35-9.
�
INSTRUCTIONS:
To be filed In person or by meil with Ure CourrtyAUdita ol fhe oounty where the properfy is located. M�QY 2 8 2 �O9
Filing Oetes: 1) Reel Property: Durirg fhe hveNe (12) marths belore December 31 0/ fhe year fhe deductlon is to be efleclive.
2J Mobile Homes assessed urMer IC 6-7. 7-7 orinanulacturetl homes nof essessed as real pioperty.�p,/u/n�rn� Ne N/lreNe (72J monfhs
before March 37 0l the yoer Ne deduction is fo be eflective. �"� � N�
See reverse sitle lor atlOiGOnal insLVdions erM qualifications. GIBSON COUNT Y A UDITOR
TyPa d be'reN reauesteE (Nease theck e9 Mat app�
�Over 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credit
(/� Y' / �LCi
Is a00���1 Ne sde legel or aQUitaWe ovme�/ If Na,
❑ Yes ❑ No
H name on recortl is diflararit ttwn that of aDD�cent indifate 6eb«
seller (epplicanf musf fuve boon buyi�7 m cmtracf af loast orre (i) yea�
Addresa o1 mntratl ae�er (number entl sbaef.
aM ZIP mtle)
Key number I Legal descnption
"�`f-d5-10
4a the wovenr �sea e�e ocwaea w�++any fo�
hiaher rasidenfs7
�Yes ❑ No
Was Ihe eppGtaM 65 years of ege or mwe on Decemb 7 d lhe year
DtlOf t0 thB Wrtettl y02/1
Yes ❑ Na
Adjusted gross income of applicant, spouse, and any
individuals sharing ownership (ForOver 65 deduction, income
may not exceed 525, 000; for the Over 65 Circuit Bieaker Credit,
incane may rrof exceed 530,000 for individuals, or 540,000 for
manied couples).
Have yau filed tor erry 01her
❑ Yes
Have you (ded fw deductions in eny dher cwMy7
❑ Yes
� Na
� No
If owned with someone other than spousa.
indimte wiih whom
Is �^e D�Oat�y i0 QuBSiion:
� Real prope ,ry � Mobile home (IC 6-14-n
Record number Page number
a �
�
ApDlimnt's date of birth (mmN, day, yoaQ
/�- ��
Source of Inwme
If Ws, what EeOuctions?
I( T§s, what counry?
i 7. wrtent year (may nof arcoatl E192,a30
Ovor 65 C"uctuf &eeker Cratlin
If filec by a suniwig. unmariec spa�sa.
what was the spouse's age at the time
of deaN?
Amou'rt oi Income
s
S
TOTAL I $ 0.00
1/We certify under penalty of perjury lhat the above and foregoing iniortnation is true and cortect and that the applicant was a resiCant
o( Indiana and owner of the aforementioned property on March 1, 20 _
Signehre ol app�iram Addrasa of aDPUm�� (��baend stroef, ci,y, sfare, arM Z/Pmde) �
d�����"�/��� �G �� % /f
Sgnatura U auSpqnzed rapresentative Address of euthorizad reGrasentative (numberarN strool, ciry, stafo, and LP code)