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APPLICATION FOR SENIOR CITIZEN couNn TOWNSHIP � YEAR �
r._. _ PROPERTY TAX BENEFITS I
S SbtB Fortn 43708 (R919-OB)
u�. � Prexribed hy the DaparLmeM of Local Govemmem Finance ��
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Information wntained in this Eowment is CONFIDENTIAL pursuant to IC 6-1.142-9 and IC E7.1-35-9.
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iNSraucnoNS: MAY 4 — ZQ��
To be filetl in person or by mail with fhe CountyAuditor ol the county where �he property is located.
Filing Dates: 1J Real Property: Dunng fhe tweNe (12) months be(ae December 37 o7fhe year the deduction is t�'be�
2)� Mobile Homes essessetl untlei IC �7J-7 or manu/actured hanes rrof assessed as raePproperly: Dunrig the 12J mont6s
be(ore March 37 olthe yearthe deduction is to be eHective. GIBSON COUNTY AUDITOR
See reverse sitle lor atld47ona1 lnshudions end qualifications.
Type o( beneft reque6ted (ploese M Naf apply�
er 65 Dad�ction 6om Assessed Valuation er 65 Circuit Breaker Credit
Nama �Wcam �o�er a anuau euyeh
� � �
Is aD � �t the sde lepal or epuitaNa f o, what is hislher axad share a interest9 tl owneE vnth mmeane o�her than spouse,
indipte with whom
es ❑ No
It name on ramN is diReraM than thal of applicanl, iMicate below
Name at cwri2d seller (epN'�cant must Aave beon buyirg m cmvact at least orre (�) yea�
Addrass N conL•aa saAer (numba aM strae4 �; sbR, aM ZIP co0e) is tne orooerty in ouestbn:
�/ _� '1 -0 �—�Q / , /� _ Q � � Real pmpetty � Mobile home QC 6-04-7J
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Tazing distria Key number / Legal Eescdplion RecoM numCer Paga r.um5er
Is Uie o�PeM1y usetl and occupieE pnmany br Pssessed value of the pmverty as of Ma¢h 1, cunent year (may not ezceed 5f82.d30
hisRier residenra? Wr Owr 65 deduction, a- 5160.000 Ior tho Ovor 65 Cilcuif &oaAror Credin
e5 o No
YVas the apoficaM 65 yean of age a mora on December 31 e year
Have you (Jed (or a(ry othar detluctians4 �f Yes. Mfiaf deductions?
�Yes �No
Have you fJed (or Caductioro in eny other coumyl II T§s. what counry?
� Yes ❑ No
I/We certify under penalry of perjury that �he above and foregoing infortnalion is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Sipnature o(aooikam Pddresa of ao0limnt (numboreM sboof, city, stale, a�M ZIP mde)
/ � V �O
Signatura W authwa rao�sentaWe Addresa ot aulMrizad reorasentative (numberanC stree4 �ity, state. and LP cotleJ