Age_Brown (5);
APPLICATION FOR SENIOR CITIZEN
r. .rt � PROPERTY TAX BENEFITS
� �' Sble Fwm 43708 (R919-08)
Prascnbad by the DeoaRmert of Loral Govem`rent Financa
Ir�C�1C'�I: �' s�'.Q`.1
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Irt!ortnatbn containeE in t�is document is CONFIDENTIAL pursuant to IC 6-1.1-72-9 and IC 61.L35-9.
INSTRUCTIONS: �a� � �-
TobefiledinpersonorbymailvnthfheCountyAUtlitwolthe�untywherelheproperlyislocafed. GIB$ONCQUNTYAU41Tep
Filing Dates: i) Real Property: Dunng fhe tweNe (12) mmfhs befae December 37 of the ysar the tleduction is fo be eHecfive.
2) Mo6i1e Homes assessed under /C 64.1-7 or manu/actured homes not assessed as �eal property: Dunng fhe twehre (72) monfhs
6e/o�e March 37 0l the yeer the detluctlon is fo 6e e//ective.
See reverse side IweOdifionel insWdions arMQualifications.
Type of beneH radu�es,!.e(Q_,(p/oase Meck aB Naf appfy)
�tC I Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
�,�
Name of iraM (mrtrer or cmtmct G�yvQ
a ` �' � �
Is aoC�imnt lha soia legal or equitaDle owne(! If N, w ai is hisfnar azact share or ir.teres�? �f ov+nad adh mmaona otner iban spouse,
indifate with whom
Yes ❑ No
If name on reco�d is diflarent ihan Ma1 ot eo�kanL ��dicate bebw
Nama of mitad 6aller (eppGcant musl have beon Ouyinq on ca:✓act at loast orre (1) yca�
Addreas ot mntratl seller (num6eramJ strcet, cM. stafo, errd ZIP code) �s ihe D� eM ir cuastion:
Real prope ,ry � Mobile home QC 6-74-�
� Tacing d' lnct Key num6er / Lapal no�ion Recortl numSer Page number
� 6-/o1-�a��3vo -oo o. oa i
Is ihe prooeM used end occupiad Odmarity hr Assessed value of the oropany as ol Ma¢` 1, curtem year (may no! erccedSiH2,a30
his�her residence? (or O�er 65 dotluaion, w 5160.000 hr Ne Over 65 C'ucui: &eaker Crt�di�
�Yes ❑ No
Waa the appticarit 65 years ot age or more on Oacem6ar 31 ot lha year
Have you file0 for eny Wher deductions? If Yes, what deductiors? '
Yes ❑ No �� ,
Mave you fded tW CaEuctions in any othar counry7 If Yes, wnat county?
� Yes � No
INVe certify undar penalty of perjury that the above and foregoing iniormation is lrue and correct and that the applicant was a resident
of Indiana and owner of the a(orementioned property on March 1, 20 _
$gneture of a0d�nt AEdress of appiirant (numee� ar.tl s4oet, ci,y, s(oto, and ZIP co0e)
� �
� �� CL/�,{,d_� //O �-� ` ,
Signaturs of auLhwized re0�asantativa Mdrass of authorizeC raa�eser.tahva (numbcr and 512ef. c�:y. statc. and ZIP code)