Age_Stanton� APPLICATION FOR SENIOR CITIZEN
R � PROPERTY TAX BENEFITS
` � - , State Fmn 43708 (R9 / 9-OB)
P �be0 ih Oapanmem of Local Govemmem Finance
u resrn by a
Intorrtiatiom m�tainetl in this Coament is CONFIDEN7IAL pursuant to IC E1.1-12-9 and IC E1.13 9.{
COUNTY I TOWNSHIP
INSTRUCTIONS:
To be (led in persm or by meil wtth the CountyAuditw ol fhe county wheie the property is located. � C T � 2 2 ��9
Filing Dates: 1 J Real Prvperty: Dunng the fweNe (f 2J marths be/ae Decembar 3 f ol the ysar the deduction is to be eNecNre.
2) Mobile Homes assessed under IC & 7.7-7 or manWeCuretl homes rrot essessed as �eal- erty: Du�the fwaNe (72) months
before Marci+ 37 0/ the year the deduc6�on is to be eflective. ��0. �
See�eversestle7oradddionaltnswdionsantlqualifications. GIBSON COUNTY AUDITOR
TYDe o( beneft �eauestetl (dease fA6ck a0 fhat aPP�
— L[f �bver 65 Deduction from Assessed Valuation � Over 65 Circuit Breaker Credit
Name of apWicam (owrror a cf Duye�
�I �
U applipM the sde lepal or ea i e owneR If No, what 6 his/ner exaG shara w interes�? N o-xned wilh svne�
indicata witA vMm
�es ❑ No
u name «i racwd I: a.1ferem ma� aw� a eco�Ce�t i�dzete herow
Duyinp m conUaIX al least orre (i) yearj
� I Pddress W con d ealler (numba aM atree4 cily, sfafa, aM ZIP oo0e)
Legal dexription
Is'the G�GeM use0 aM ottuWed G�mariry lor
hisRier residante7
�Yes ❑ No
Was Ihe eDM�m 65 yeen o( ape ar more on December 31 of ihe year
priot to Me artaM yea(7
� Yes ❑ No
Adjusted gross income of applicanR spouse, and any
individuals sharing ownership (For Over 65 deducLOn, income
may not exceed 525,000; Joi the Over 65 Circuit Breaker Credit,
ixome may rrot exceed 530.000 for individuals, or 540, 000 fw
mamed couples).
Have you filed tw erry other deEuctional
�Y85
filetl tor deCUCtiona in eny other county)
� YBS
� No
�
IS t0e ploDehy in Qu85lqn:
r(�F — /l.lJ "f7 i
Assessed value of the D�
(or O�er 65 tlotludion, or
spa:sa,
property � Mobile home (IC 6-7-7-n
IIVJe ceNfy under penalty of perjury that the above and foregoing infortnation is tr�e and correcl and that the applicant was a resident
�of Indiana and owner of the aforementioned property on March 1, 20 _
Sgnaturedapplicarit Md�essotappli�M (numbaenOStroef,city,stafe.a�NZlPCOtlo)
� ��% � %
cinna� . M authenzed reora�emative Address of aul 'zad representative (numDar a� sLeet, ciry, state, and LP catla)