Age_Frederick� APPLICATION FOR SENIOR CITIZEN
- PROPERTY TAX BENEFITS
S ,�• Sbte Foem 43708 (R9/9-08�
P�escrbad by lha Deoartmant ol Local Govamment finance
C�
In'ortnatian containetl in this document is CONFIDENTIAL pursuant to IC 6-1 J-12-9 and IC 6-7.135-9.
COUNN � TOWNSHIP � YEAR j
I _
� � ile ar
wsrRUCnoNS: ' DEC 1 'L 2008
To be filetl in person o� by mail wdh fhe CounryAUditor of the county whera the property is located.
Fili� Dates: 7) Real P�operty: Dunm� the tweNe (12) months befora Decem6er 37 o7fhe year fhe deduction is to be eHecfiv . �/J
2) Mobi/e Homes essessed under IC 64J-7 ormanufactured homes nof assessed es real property: Dunrg the�i�4Jm /
6e/ore Mardi 37 o7the, yearthe deduction is to be eHactive. GIBSON COUNTI' AUDITGR
See reverse sitle for adddionel lnshudions erM qualificaGons.
Type of benefi reQUe9ed (poaso Mock a0 Nat apWy�
� Over 65 Deduction 6om Assessed Valuation
If No, what
❑ Yes ❑ No
It name an recwd is ciRarent �nan that af aoa�rcan4 �Mifa�e bebw
exaGt
sailar (apd��anf must have been Euyirg on confract at /oast ono (i) ycarJ
�� Pdtlrau of mntract seDer (numba aM sbcet, crty, stalo, entl ZIP code)
DmDeM ��' and occuped pnmany tor
r rasiden�7
�/
Yes ❑ No
Waa the eoW�wM 65 years o( epe or mwa or Decamber 31 of t�e year
o�or to ihe wrrem yea(!
� Yes ❑ No
Adjusted gross income of appliwnR gPouse, and any
individuals sharing ownership (Fo�Over 65 deduction, income
may not exceed 525, 000; (or the Over 65 Circuif Breaker Credit,
incane may rrot exceed 530, 000 tor individuals, or 540, 000 for
mamed couples).
Mave you (led fw any
Have you fJad fw detluctions in any
� Yes � No
7
� Yes ❑ No
�f Over 65 Circuit Breaker Credii
. �
�����
ir.terest? If owned vnin someone othar ihan soouse,
if.EIC2�8 Wi�h w`OT
tha omoerry
Real propery � Mobile home (IC 64-f-�
1�/o� ^Racord numSer Page r.umber
<J 0
Assessed value of the o�oe2y as of March 1, cur.eni year
(or O�er 65 dotluctim, w 5160,0001or the Ovei 65 Circurt i
Income
IF Yes. what deductions7
�� 9�
If Ves, wha� tounry?
IIf fdec 6y a surviw:5. �n:ramed spouse,
wF.at was lha smusa's a6a at the time
of daath?
� Amount of Income
IS
IS
TOTAL I S 0.00
I/We certify under penalty of perjury that the above and foregoing informabon is true and correct and thal the applicanf was a resident
� of Indiana and owner of the aforementioned property on March 1, 20 _.
SgneWre ot a�pGwr.f Adcress of apDlinrt (numC=rar,d sfrool. c�y, s:ate. and ZIP cotle)
�// l � , � �d
� Sgnature W euLlodzed reoresentative I ACCress ol aulAOrizet reaasentative (numEer anC s:rce(, ci,y, stafc, and ZIP code)