Age_Sisk�"' APPLICATION FOR SENIOR CITIZEN couNrv TOWNSHIP � YEAR
4 PROPERTY TAX BENEFITS
�� , Sdte Fortn 43708 (R9 / 9-08)
� Prawibad by ihe DeparimaM of Loral GovemmeM Finance
• File Mark
Intwmation contained in Nis tlocumenl Is CONFIDENTIAL pursuan[ to IC 6-1.1-12-9 antl IC (i1.135-9. �����
INSTRUCTIONS:
70 6e filed /n persm or by meil witA Ure CounfyAUdita o! fhe munry where fhe property is located.
Filing Dates: 1J Real Property: Ounng the IweAre (72) months 6efoie Decem6er 37 o7fhe year fhe deduction i.���§ etjec�ive��
2) Mobile Hanes assessed urMer IC &1.7-7 or manu/ectured homes not assessed es reel propeRy: t3�rr�rcj fAe (72) months
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be/ae March 31 0l the year fhe tletluction is fo be eftective.
See ieverse side la adrlifional fnsUUUions arrd Qualificafions. /�% �Q
Typedbe�reF.trepuested�pleasecAxkeONatappry) �-�� GIBSON COUNTY AUDITOR
er 65 Deduclion from Assessed Valuation � Over 65 Circuit Breaker Credit
Name of apd�m (owrre� or cantraG DuyoQ
Gl9/t. S/5/�
Is ap0���1 Ne e legal ar eQUiWde wmeR M No, what is hislnar exad share w interesl? H axned wilh somaone mher lhan spousa.
indimte wilh whom
C� p No
M neme on reco�d is diftarem lhan that d epd�nt, indicate bebw
Name d mnaa seoer (aaP�enf musr naue eeen D�yinp m cmuacr af reasf orre (�) Y�tl
Addreea W contrad satler (numbm aM abeet, cily, s7ale, end ZIP mde) Is ihe prooerty in Questbn:
_ �eal property � Mobile homa (IC 6-74-�
Taztrp Clsirict Key numbar I Legal Eescnotion � Record numbar Pa9e number
r�n n a�-ii-ia-a�3.-doa.�,, -�a8
b Ihe propeM used and ottupied pnmarity br � Assessed value of lhe O�OeM as of March 1, wneM year (may imt exceed 51B2,d30
his�her reaidenoe7 lor O�er 65 deduclim, u 5160.000 for Ne Ovei 65 Circuit Breaker Credi�
Yes ❑ No
Waa lhe applkam 65 years ot age or mae on December 31 af the year
Have you fJed tor eM �er Eatluctima4 �l Vus. M1u1 ded�ctions?
❑ Yas No .
Mava you fJed lor deduc6on5 in any other cw�riyP �t res, what county?
� YBS � NO �
IIWe certify ander penalty of peryury that ihe above and foregoing in(ormation is true and covect and that the applicant was a rasidenl
of Indiana and owner of the aforementioned property on March 1, 20
Signalure of apd�M Pdtlress of aoo���1 ln�rrrGerantl sboet. ciry, state, aM ZlPcode)
/ O/ L✓� yJ2U/nritLD - i/1/n/[i %D� ��✓ ,��
Sgnatura of a - ed resantaWe Address ot autMnzad reprasantative (numbw arM suret, ciry. stafe, and LP cod