Age_Pyle�
�. "' p APPLICATION FOR SENIOR CITIZEN n,� row a e.nr:
. PROPERTY TAX BENEFITS
` -! Spie Fortn <3708 (R9 / 9-OB)
Peascrbad by ihe Deoartmem of Lacal Govemmem fir;�ce D C 1 1 2�0
File Mark
Intwmation oon�ained in lhis tlowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. �l� �`��
��
INS7RUCTIONS: � U
To6efiledinpersonorbymailwifhNeCountyAudiforolthecounywherefhepropertyislocatetl. GIBSONCOUP!TYAUDITOR
Filirg Dates: 7) Real Property: Dunng the MreNe (72J months before December 31 ollhe year the deducfion is to be eflective.
2) Mobile Hanes assessed untler IC 6-iJ-7 ormanWac(ured homes nof assessed as real prvperty: Dudng Ne Mre/ve (72) months
6efwe March 37 of the year fhe detluctlon is to be eNecfive.
See Ieverse side lw adtlitional instiudions aiW qualihcafions.
I-' 1
�
Type of benefit reGUestetl (Woaso d+eck aD Nat epply)
� Over 65 Deduction from Assessed Valuation
of aDdi�'ant (owrwf ar cmtrsct Duyerj
sde legal or apuitaWa owneR / If No, whai is
❑ Yes ❑ No
�Over 65 Circuit Breaker Credit
share or i.^.teresl7
N nama on retoN is Eifterent Nan that ot aoW��4 �ndicste bebw
Nartre d corrtrea sa0er (appticent must have Dcon euying m conLact at Mast orre (1) yea�
Address of mntred
cM. sWfo, and ZIP codo)
Key number
With $Of1180:18 0��2! �hd0 SpOlISB.
wiN w�om
Is Ihe oroo rty in cuestion:
�eal propery � Mobile home (IC 6-74-�
� Recok num6er Page number
�"/,;c�tic�dr.� �6-/l - g'- yoo- ooa. � �I-v �-;
Is Ue pmoeM usad a� occupeC pnmany br Assessed value of t`e oroperty as of Marc
hisfier residence7 for O�er 65 doAUIXian, w 5160.000 !or the
Yes ❑ No
Was Ihe eDW�m 65 years of ege w mora on Decembar 1 of ihe year
I/VJe certify under penalty of perjury that lhe above and foregoing information is We and correct and ihat the applicant was a resident
of Indiana and owner of the aforementioned property on March 7. 20
eulhonzaC
AdCress of aop�Kaq (r.umGer antl sWet, ci,y, stafo. antl ZIP
J
eut�orized reoresenta�iva (nomhCf Jntl 5:/OCL Lity. SdtC O�tl ZIP COdC)
�•. �