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"� . i ��� COUNTY TOWNSHIP ' YEAR
. APPLICATION FOR SENIOR CITIZEN , 1
PROPERTY TAX BENEFITS '
riiiState Form 43708 (R9I 9-08) / acCVN.
i-I f Prescribed the Department of Local Government Finance ! 2s-
by Oattme l. J
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Information contained In this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. `� T
1- 1 6 •
INSTRUCTIONS: S E P 3 0 2009
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the twelve (12) months before December 31 of the year the deductionjs to be effective.
2) Mobile Homes assessed under IC 6-1. 1-7 or manufactured homes not assessed as real props J hng Ivs (12) months
before March 31 o1 the year the deduction is to be effective. g
GIBSON COUNTY AUDITOR
See reverse side for addition/instructions end qualifications.
Type of benefit rvcues:ed (please check rip that apply)
❑ Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name d apbb ant (
If No, what is tuslher exact snare interest? li owned with sorAC a other th strou
indicate
w!1om ,9'Y
es El No I
6
It name on record is different than that of applicant, indicate below �
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Address of contract seder ( bar and street. city, state. and ZIP code) Is the aroaerty it cuastion,:
eat property Q Mobile home (IC 6.1-1-7)
Taxing die Key number I Legal description I Record number ' Page number
i /LO('CJLi-d)L a 6---11,10 SDI-6:03 o —007$
Is ttie protorty used and occupied pnrnar y for Assessed value of the property as of Marth 1,current year (may not oxmcd S:82,430
blether residence? for Over 65 deduction. or$160,000 for the Over 65 Circuit Breaker Credit)
❑ yes ❑ No 11
t
Was the ao tcant 65 years of age or more on December 31 of the year
prior to the current year'
❑ Yes ❑ No
Adjusted gross Income of applicant, spouse, and any
individuals sharing ownership (For Over 65 deduction, income
may not exceed S25,000; for the Over 65 Circuit Breaker Credit,
income may not exceed $30,000 for individuals, or $40,000 for
married couples).
Have you fried for any other deductions? . •
Ybs n No
Have you filed for deductions in any other c linty? If Ars, what county?
0Yes o
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of aa0bcant Address of applicant (number and street, city, state, and ZIP codo)
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Signature oi auL'r,or`.ze0 ro>lsrrtzUve Address of authorized representative (number and street, city state, arid ZIP code)
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