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O"' u APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
Stlle Fortn d3708 (R919-08)
� a. � Prascnbed by Me Oeoanmeni of Local GovemmeM Pirance
COUNTY TOWNSHIP � YEAR
il
In`armation contained in this doament is CONFI�ENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9. ���� p �
INSTRUCTIONS: �—�
To be filed in person or 6y mail with fhe CountyAuditor o/the county where the ploperty is located.
Filing Dates: 1) Real Pioperty: Dunng the Avelve (12) months be(ore Decem6er 31 of the year the deductionQ�oCbe �/7e�'�iv�008
2J Mobile Hanes assessed under IC 64.1-7 ormanWactured homes not assessed as real pmpeRy: Dunn9 the MeNe (12) months
DetO/B M8lCJI J1 Of Ille yea! InB oeaucuon rs m oe ei+ecwe. ''�i� �
See reverse side fa atltldional instrudlons arM qualifications. !�'� ��'�'
Typaofbanefitreuuested(WeaserheckaUNatapplyj GIBSON COVN
e� 65 Deduction 6om Assessed Valuation Over 65 Circuit Breaker Credit
Name o! a0d�m (o mer or cmHacf buyoq ��-Z`" "_" `
�
Is a0olimnt Ne sola legal or eQUitable owneR I( No, what is iislher exact share or interest? If owned with someona ot�er ihan spovse,
InL�iC2lB W1�t1 WfOlf:
❑ Yes ❑ No
if nama on recoN is diRerem than that ot aod��L ��dicate bebw
Name of mntact sellar (apWicanf must Aaro beon buyirg on contratt at /east orie (i) yearj
P4tlress of contrad selier (numGwaM svee�. ciry, state, anC ZIP wde) �s ine omoerty in oueslior.:
Real propery � Mobile home (IC 6-7-7-�
a ' G_t =ti �=�o.�=oo' -%% .
Taeing dist, w1" ""'� I Key numxr I �egal descr�tion I Recortl number Page number
� I
is �he DmOeM useC anC occupieC o�manly br A:sessed value of ihe orooeny as of Mamh ;, cur.ar.t year (may no( eacaed 51H2.a70
hisiher residanca7 br Oi.er 65 deduCirn, w 5 f 6G.00O 1or tno Over 65 Circvi: &oaAror Crod�t)
❑ Yes ❑ No
Waa the apWcam 65 yean of aga or mwa on Oacam6er 31 of tha year AoolifanYs date of bi;th (monN, Cay, yea� If fi!ec by a suniving, unmameC s�ouse,
orior to the arreM yea(7 what was tha soousa's a5e at the hma
� _� � —� of deat.?
� Yes ❑ No
Adjusted gross income of applicant, �pouse, and any � 5ou af ncome � � Amount oi Income
individuals sharing ownership (ForOver 65 deduction, income I I 5 L 1� 4
may not exceed 525,000; for fhe Over 65 Circuit B2aker Credit, T U
income may rrot exceed 530,000 tor individuals, or S40,000 for I ( S
manied couples).
ITOTAL I S 0.00
Have you (Aed kr any aher daductionsi if 1?s, �xhat ceducncrs?
C� ❑ N�
Have you fded for deductions in any Wher cwnry7 I If t?s, wi�at cwrry?
� Yes ❑ No
I/We ceAi(y under penalty of perjury that the above and foregoing information is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20 _
Sgnature d applkam AdEress of aopGmr.t (r,umberantl sveel, ci,y, state, and ZIP cod )
/` � � D -� • �2C.�� -�,�� � '
Sipnatura d euMadzed reD�esentative Atltlrass of autnorizec :asesentative (numDer arM s:reel, ciry, uate, antl LP code