Age_Zelko� APPLICATION FOR SENIOR CITIZEN
. PROPERTY TAX BENEFITS
` '! Stafa Fartn 43708 (R9/ 9-OB)
P'exnbed by the Departmem of Local Govammem Finaxa
� I
Infortriation oontained in this dowmenl is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC f.1.135-9.
COUNTY TOWNSHIP � YEAR j
�
}� }j..-.J .�.i1BA4
wsraucnoNS: OCT 1 5 Z009
To 6e filetl in persm or 6y meil wifA the CountyAUdRa ol Ne county where the propeify is locatetl.
Filirg Dates: 1) Real Pioperty: Dunrg the hveNe (f2J mmths be(ae December 37 o/the year the deduction is t"op�effecliv�7�
2) Mobile Hanes assessed urrder IC 67. 7-7 or manu/ectured homes rrof assessed as real properry: Dun6r�he Mrefv_9 (72) mmfhs
be%re Merrh 37 o/the year the deductlon is to be eNective. GIBSON COUNTY AUDITOR
See reverse sitle !a adddional insWdions end qualifications. , /
ryoe a teoeE� reauestea Ipaesyerock m tnat eaaM
�Over 65 Deduction from Assessed Valuation � C
Name Wkerit(owraratMbeclEVyaQ
Ia eoPlimm Iha ade lapal or eQUitade R � No, what u his�her exap s� a w interest?
es ❑ No
11 name on retoN is EiflareM Ihan Ihat ol apWKant indicete bebw
Name m conuaa
on tonVad
aeller (numDa eM atroot, city. stalo. erW ZIP co0e)
'ng districl Key numbar I lepal
ab -I�-► -lo -c
b ihe pfoperty used and ottupied pnmarily br
hisRier rasiOencel
(7) Y�0
Yes ❑ No
Wav lhe aOW� 65 yearn of ege or more on December of Ihe yaer
prior to tha a�rtent yea(1
Yes ❑ No
AdJusted gross income of appliwnt, spouse, and any
indivlduals sharing ownership (ForOver 65 deduclion, income
may not exceed $25,000; /or the Over 65 Circuif Bieaker Credit,
income may rrof exceed 530, 000 for individuals, or 540, 000 for
married couples).
eny
Mave you filed for dedudiona in eny
� Yes ❑ No
� Yes � No
65 Circuit Breaker Credit
�ha
tl owned
I(1dIWIB'
5pW5e.
I propery � Mobile hame (IC 6-7-1-�
numher � Page number
omoerry as of Mamh 1, curteri year (may nof exceed 5182,4?0
ar 5760.000 hi Ne Over 65 Cirnut Breaker Gedi�
-
� � .�
I/We certify under penalty of perjury that the above and foregoing information is true and correct and lhat the applicant was a resident
ot Indiana and owner of the aforementioned property pn�. ao ao 0 9
� ' naturadeppika P4dG�essotapptimnt (numberaMStroe4ufy, fe,aiMZlPwde)
� /O'� W. Q.4�,fiC�W �Vl.
�LG�. <�' i c� 0 7 G7o- / o
Sgnature o1 eWhorizeO fe0 taWe - Addrass of auihorized raD�asenialive (numberarM suce4 ciry, 5ate, and LG code)