Age_FolsomAPPLICATION FOR SENIOR CITIZEN
' PROPERTY TAX BENEFITS
` Stam Form a37o8 (R9/ 9-08)
� Pfasaibed by the Departme�rt ol Local Govemmem Financa
�
Informatbn wntained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
C_ �
INSTRUCTIONS:
To 6e filed In person oi 6y mail with fhe CourrtyAuditor o/tAe county whe�e the property is locatetl. MAY 2 1 Z��9
F!lirg Dates: 1) Real Property: Dunrg the fweNe (12J months 6efore December 31 0l fhe year the tleduction is to 6e eftective.
2J Mo6ile Hanes assessed urMer IC 61.1-7 or manulactured homes iro( assessed as real p�oper–f�y Dy�unrg fhe fwelve (12) months
befwe MafM 37 olfhe year the deduction is to 6e eHective. !i'� � r� �
See ieverse side lor adddional insLUCfions aM qualificetirns. GIBSON COUNTY Al1C1ITOR
ecWkam
Over 65 Deduclion from Assessed Valuation
�0
Over 65 Circuit Breaker Credit
la a001ipM the sde iepal ar aQJtable ameR �� U No, what ia his/ner ezad sh'ara dr interast?
�'1�es ❑ No
If name on ramrd is diRereM Ihan Ihat d applifant, indiwte bebw
Name of coMroct sa0ar (a�m&'�anf must hero Doon Euyirq m cmfraa af leasf orie (1) yoa�
AOEIB59
aM atree4 cip', sfefe, aM ZIP mda)
Key numher /
J X� �_ I d�-d�-a a-�
U N—e p M use0 aM octuped PrimarJy br
hialner reaidente7
es ❑ No
Was Ihe eoN�M 65 years ot age w rtrore on Decembar 31 e year
0�<<0 �he arteM yea(!
Yes ❑ No
Adjusted groas ineome of applicant, spouse, and any
IndNfduals sharing ownership (FOrOver 65 deduction, income
may not exceed 825, 000; 7or the Over 65 Circuit Breaker Credit,
income may rrot exceed $30,000 for individuals, or $40,000 (or
mamed coudes).
filad Iw a�ry other ded�xSOna?
�–� 1°°
Have you filed for ded Wions in any other cauMy7
� Y85
� No
�ni�Li
M owned with someone oUer Inan spouse.
iMipte wiN whom
a o�oeM �n auestron:
� Real proparry � Mobile home QC 6-7J-�
Record number Page number
�. Da�'��� I
Assewed value of Ne prooe(ty as at Ma¢h 7, wrtem year (may rrof exceetl 5782,d30
PoiOw� 65 tlotlurlim, ar 5160.000 fur Ne Over 65 Cticud &eaker Cretli�
IIWe certify under penalty of perjury that the above arfd foregoing information is true and coRect and lhat the applicant was a resident
ot Indiana and owner of lhe atorementioned property on March 1, 20 _
pnelure of aoWiram � Q P.dtlress of applifant (numbwnnd sbeet ciry, sfate, arM ZIP code) � j y/ M
��/, n��`�� o a K< �r �•� D �
� p�� 51,i7s Si I��S� 5�76Au
pneture W authorized reoresemawe Addresa of auttaraed re0easentative (numbe(arM s✓eef. pry, state, end LPCOde)
�
.;'
,.-.F*k> APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�% N PROPERTY TAX BENEFITS Setrtervl Ile
wl ,i' State Form 43708(R15/1-20) G 1 bso 2
� -, Prescribed by the Department of Local Government Finance
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Date: Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the following
January 5 of the calendar year in which the property
Type of benefit requested(Please check hat apply)
Over 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer
C hcs-\eS -Ft(So/1-1
Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
E f s ❑No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common reside on the property?
s ❑No
Name of contract seller Has applicant owned or been buying the property under recorded contract for
at least one(1)year before claiming deduction? 1..'f6-s ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
al-Real property El Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
0-7o-02-'- O\ -DOO 038 - 00S
Does applicant reside on property? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
es ❑No [counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
Have you filed for any other deductions? If Yes,what deductions? 1 /►,, �I
�-Yes ❑No �twte S6C I PAOJ-F,-e
Have you filed for deductions in any other cooun�t ? If Yes,what county? l
❑Yes L�No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applica Date(month,day,year)
eZe
Address of applicant (number and^strvet,city,state,and ZIP code) L� Q
5�/7 S S-ta-F4 Ind2 -7 I 4-
Signature of authorized representative Date(month._davlx d A1(/NI10�R>Ir0>�@�
Address of authorized representative (number and street,city,state,and ZIP code) '�77 7 p / T
Signature of C unty Audi -� w
Date(month,day,y2ZOZ a 0 d3S
kldl
„Ira-
-(1:) FILED aa
4,_ . , t11 'in cj e • SEP 08 2022
r
GIBSONCOUNTY AUDITOR
DISTRI : Original-County Auditor; File-Sta peal Copy-Tax