Age_Kingsbury� APPLICATION FOR SENIOR CITIZEN
, PROPERTY TAX BENEFITS
S ' Stam Fwm 43708 (R9 / 408)
Prasttibed Oy Me DeOartmeM of Loral GovammeM Finance
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Informatbn oonfainea in �his dowment is CONFIDENTIAL pursuant to IC 6-1.7-12-9 and IC G1.73S9.
COUNTY I TOWNSHIP
INSTRUCTIONS: o
To be fileC ln person or by mail wrfh the CountyAUditor of the county wAere fhe property is loce(ed. � U N J 2��9
Filirg Dates: 7) Real Pioperty: Dunry lhe AveAre (12J months be7ae Decembe� 37 0/ fhe ysar fhe deduction is to be eReclive.
2) Mobile Hanes assessed under IC 6-7.7-7 ormanWacfuretl homes rrol essessed as real property. Ihe hygl� !72) monfhs
6e/ore Merch 37 o/the year the deduction is to be e//ective.
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See reverse side tw adddional inst�uctions end qualiBcations. GIBSON COUNTY AUDI70R
ryoe n cenec� �ea�as+ea Idease mxx a¢ w� e�
❑ Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name o( eoD��M f�� a canlydu OuyBQ _
V � �
b apolimm tna sde le9al or eQUita ownaR If No. wh u hisRi r azacl share w intaeasl7 If owned � eone other than s0oase.
indifate xi om
Yes ❑ No
H reme on recad'u dtfarem than Ihat of epplimnt, iMicata bebw
Name ot comrea se0er (a icant must hava boon ouyirg on cmvacf at loast ono (7) yeeh
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Adtlreas af mntraG se�er n�mbw end sbeef, uy, sbfe, anL ZfP mtle) Is ihe prooerty in Quesiion:
Real property � MoDile �ome (IC 6-74-�
Tazin distntt KeynumbarlLegaldescnplion Recordnumber Pagenumber
�i • 3-od-3oo -ao . 3� �o
Is Ihe perty use0 and occuoied pnmarily (or Assessed value of the propeM as of March 1, cunem year (may rrot erceed SfB7 a30
tilvhe reaidence7 lor Owr 65 tlotlurlion, ar 5760.000 for No Ovor 65 Circuil &ea/rer Getlin
�Yes ❑ No
YYas ihe eppGfarM1 65 yeaia of age ar maa on December 31 of the ywr .
rwve r«� ruee lor em ou,er aeaucOwis4 tl ws. w1w� deductioris?
� Yes � No '
Have you (Jed M dedu�lions in any other murrty7 �f �§s, whal counry?
❑ Yes No
INJe certify under penalty of perjury that the above and foregoing information is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
SignaturedappllcaM „ PddressoleppGtani(n�xnbwarbsbeef,cily,5lato.eMZ/Pcode)
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Sgnature of auNaAzed raoreaeMative Addresa of authonzed reo�esen�ative (numberaM sLOeq city, stafo, anE ZIP code)
�g�,�o �' SRGS'
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