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� �'�" APPLICATION FOR SENIOR CITIZEN cOUrrTY TOWNSHIP v�4�t
PROPERTY TAX BENEFITS
Stala Fwm 43708 (R9 / 9-08)
�•�• � Prasaibed by MB DeparlmaM of Loral Govammerit Finance
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Informatiom m�iained in this document is CONFIDENTIAL pursuanl lo IC 6-1.1-12-9 and IC G1.1-35 .
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wsraucnoNS: JAN 9 2012
To be fJetl in person or by mail wifh fhe CountyAuditor o/ the county where fhe property is locafed.
Filing Dafes: 7) Real Property: Dunng the tweNe (12) months 6e�ae December 37 0! the ysar the deducGnfijSfo.beaHective.
2J Mobile Hanes assessetl under IC 67.1-7 or manNactured hanes rrot assessed as ieal pioperty: DUCrg We�twelve (12) months
befaeMalclr37o7theyearthetleductlonistobeeflective. GIBSONCOUNTYAUDITOR
See �everse side 1or addifional insWdions a� qualificafions
Type d banefit raquested (p/ dieck a� Naf aPpty)
Over 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credit
oravo6 mf�arconnactaure9
.
iartl tha sde legal oreQUitable wmei
name on
Nama of mrt(ad
If No, what is hisRier ezad shara w inta(est7
�-r ❑ Na �
is diRerent Ihan that o(a0d�nt ind'kate bebw
AdCress ot mntrad seDer (mm6er a�M sbeet �'. sbb.
m cantract at least arro (f) Y�7
If owned wilh wmeona mhar Ihan spouse,
intlitate with whom
i LP code) Is the prope�ty in quesfion:
� Real pmperty � Mobile home QC 6-74-�
Key numher / Legal desaiptim Recad number Paga numbar
-Odo. S a�
0.ssessed value ot Iha properry as of Mamh 1, wnant yaar (may rrof erceeC E7B2,a30
�t lorOrer 65 detlucfian, ar 5160,000 (or Ne Ovar 65 Cccu1 &eaMer Credit)
� I No
Was ihe app(xam 65 years of ape w mae on December of Ihe year
pnor to ue artem yeaR
Yes ❑ No
Adjusted gross income of applieant, spouse, and any
individuals sharing ownership (For Over 65 deduction, income
may not ezceed 525,000; for the Ove� 65 Circuit BreakerCredit,
income may rrof exceed $30,000 (orindividuals, or $40,000 for
mairied couples).
you (Ja r eny olher deductiais?
� � � Yes
you file tv detluctions in any other munt/t
� YES
� No
� No
Source of Incoma
If Yes, what county7
I(fded by a wrviving, un:rertieE spouw.
what was tha spousa's age at Ihe lime
ofdeath?
AmouM oi Income
��
S
TOTAL I S 0.00
I I/We certify under penalty of perjury that the above and foregoing information is We and correct and that the appiicant was a resident
� of Indiana and owner of the aforementioned property on March 1. 20 _
r5ignalure d apqirafrt Pddress of apptinm (nunber aM stroe4 �; sble. ar+d Z�P wde)
Signature N euthw'rrzed represaMaliva I Adtlrass of aulhorizeC rapreseniztiva (numDrlaM shoof, city, state, end LPcode)