Age_Nelson� "'" APPLICATION FOR SENIOR CITIZEN couNn TOWNSHIP r�
,__ _ . PROPERTYTAXBENEFITS
State Fortn 43708 (R9 / 9-OB) �
•' � PresaibaE by the DepaRmeM of Local Go�amme(rt Fnaxe
ark
Informatiom m�tained in lhis doament is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 61.135-9.
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INSTRUCTIONS:
APR?22012
To be filetl in person or by mail with the CountyAUtlRor o! the counry whera tl�e pvoperty is located. �
Filing Dates: 1 J Real Prope�fy: Dunm� the (weAre (1T) months 6elde Decem6er 31 0! (he year the deducfion u fo be
2J Mobile Hanes ascessed under IC b7.7-7 o�manufactured hwnes raf assessed as rael property.� Dun !ve (72) months
6e%reMarcfi3foftheyearthedeductionislobeet(ective. GIBSONCOUNTYAUDITOR
See reverse side !w addifional instrudions end quali6cations.
Type o( benefi reQUesied (pleasa rheck a➢ fhat appl�
�Over 65 Deduction from Assessed Valuafion ❑ Over 65 Circuit Breaker Credit
Name d epplicar�t ( r or cnrtracf GuyEr)
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Is appfimM lhe sde legal or eQUit owneft H Nq �s is/her axa share a inieresl7 It owned with wmaone olher Ihan spoum,
�rate with whom
Yes ❑ No
H nama on racord'¢ diRarent Ihan Ihat of appihan( inGicate belaw
Nartre of conVarl seAer (appficanf musf have been buying m cmlracf af basf one (1) yrar)
Address of mntrarl seller (numbw aM sbeeL city, stafe, arM ZIP mde) Is the pmperty in pueslian:
— O —' O�7. GTQ �.'7� eal rty � Mobile home QC fi14-n
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T�ing ' Keynumber/LegalAesrription Recordn har Paganumbar
/l �I ��� I "W„`� `'� _ '
Is Ihe p(operty used and xapiaC primaay br Assessed valua of tha prope�ty az of Mamh 1, wrtenl year (may rwt erceed 5182,430
hislner rasiEencsl !or Orer 65 Oatluc(ion, w f160,000 for fhe Ovor 65 C'vc�it BrealarCrad�
❑ Yes ❑ No
VJas the app6aM 65 years ot age w mae on Oecember 31 W L5e year Applimni's date of 6irih (mmlh, da% yra�J If filetl try a surviving, unnertied spouse,
prior to Ne a�rteM yeaR what xas Ne spouse's aBe at tha time
� Yes ❑ No otdeam?
Adjusted gross income of applicant, spouse, and any
r�a yw raad ror am aner aee�:? u�, wna� aaa�aor�t
�Yes �No
Have yau Poed for deductions in any oLher cwmyl If l§s, whaf counly?
❑ Yes ❑ No
IIWe certify under penalty of peryury that the above and foregoing infortnation is true and correct and lhat the applicant was a resident
of Indiana and owner of the aforemention d property on March 1, 20
SignaturadappGcaM i- �� AdtlressafaPPlimM (numbeiarid tlry, fo.aMZlPwde)
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Signatura o( onzed rapreseritative Address of auttwrizeC rapese ive (nunDer erM slreeL �}: state, entl LP cade)