Age_Reneer�' APPLICATION FOR SENIOR CITIZEN �l''1 � couNn � TOWNSHIP � YEAR
r,. -n: ,, PROPERTY TAX BENEFITS V
�' Stata Form d3708 (R9/4-08) R —
Prawibed 5y Ue OeOartmenl of Local Govemment Fi �ance �� ��
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Informatiom m�tained in t�is document is CONFIDENTIAL Wrsuant to IC 6-1 J-12-9 ana IC 6-7.1-35-9.
INSTRUCTIONS: f� p
To 6e (led in persm or by mail with fhe CountyAUdifor o/ the county where the properry is located � E l. 2 D 2���
Filing Detes: 1) Real Propeity: Dunng the hveNe (72J months be(ore Oecember 31 o/fhe year fhe deduction is to be eHective.
2) Mo6ile Homes assessed under IC 6-iJ-7 ormanulacfuretl homes not assessed as reel property:�q{rg the tyve�72) months
be(ae Mardi 37 otthe yeer fhe deducGOn is to 6e e/lective. /r6G �' �
SeereversesideloradditionalinswcfionsarMqualifications. GIBSON COURTY AUDITOR
Type of Canefit ranuested (yoasa rhock a0 Na1 eppJy7
QOver 65 Deduction from Assessed Valua6on �er 65 Circuit Breaker Credit
Name of aDOf �(owner orcmtracf Cu� /�
j�f�i
y
I5 ap011oM Ihe de lepal or epuitaMe owneR If . ai is tdNhar ezact share w ir.teresil If a+vred with somaor,e otner ihan spa:sa,
indinta vntn whom
Yes ❑ No
If name on :ecord is diRerem Lhan ihat of aooGcan� irWiwte bebw
Name of m�t:ad eller (apqicant must have boen buy'ug on cant2ct at least orro (1) yea�
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Adtlrees ot tratl saller (numbor aM s✓ee(, cify, sfato. antl ZIP wde) Is iha omoerry in Quasiion:
eal prope ,ry � Mobile homa (IC 6-7-7-�
Tazing disin� Key number / Lagai descAOtion I ecord number Page number '
l.E%�- a�- laa�f�-000-�0�10
Is Ihe ciopeM used end occuo�aE o�many /or 0.sxssec value of the omoarty as of Ma¢� 1, wr.art year (may rwf ercccC 5;82,d30
hisl�er residenw? Por Over 65 datluction, w 5160,000lorlho Ovc/ 65 Ci¢uiI &cakerCmtlit)
Yes ❑ No
Was the aoG��� 65 years o/ aga w mora on December 31 W tne yea:
Have you (ded tor any Wher deduGions7 If Ves. wna� dedi'.�ior.s?
� � No
Havayou filad tw Eedudons in any aher munry7 I If Ves. wnat counry?
� Yes ❑ No
I/VJe certify under penalty of peryury that the above and foregoing information is We and correcf and that the applicant was a resident
o( Indiana and owner of lhe aforementioned property on March 1, 20 �
I sig�ature ot aoorwm PdEress of xoo�imnt (numterand sWet, ci.y, staro. arH ZIP mGe)
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Si a ure of aulhoAz n tiva tlress ot aulnorizetl reoresenWtive (numberantl stieel. ciry, sfafe, and ZIP code)