Age_VanVliet�
�APPLICATION FOR SENIOR CITIZEN � couNrr TOWNSHIP �" YEAR
rt . PROPERTY TAX BENEFITS ��Y
Sbte fortn 43708 (R9 / 9-OB)
` u � PrasuibeE by iha Depa�merit of Local GovemmeM Finaxa �
ile ar
Information contained in Nis Cocvment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC &1.1359.
�NSrRUCnoNS: SEP 3 0 2009
To be fiied !n persm or by mail wifA fhe CountyAuditw o/ the county where fhe property is located.
Filing Da�s: 7) Reel P�operty: Dunig the fweNe (12) mrnths be%re Decem6er 37 0! fhe ysar the deductionj,sY tyoI 6e eflective.
2J Mnbile Hames assessed urMer IC E7.1-7 or manu/actured homes rrof assessed as reel properryf� rg? � Ne (72) monihs
befaeMardi3loltheyeerthedeeuctionistobeeHactive. GIBSONCOUNTYAUDITOR
See reverse side !or addiionel insWC7ions arM pualifications.
Type d beneft (epuestad (pease rheck eC Nef apply)
❑ Over 65 Deduction 6om Assessed Valuation Over 65 Cirouit Breaker Credit
Name of epdircant (w�+� a d DvyoQ � I I- 1 r
(/K-cQ Q l,Ct/�V�cz.-/�
19 3pDIK3nt t�B Sa�e iepal or aquilaWB OwnBR If No, what u his/her eaaG share w interest? If owned with someone other than soouse,
indimte with w�om
� ❑ No
M name an recard is diflerem Nan that d epqicant, iMicata bebw
Name of mMred saller (eppli nf musf Aeve Daen buyirp m cmVact ef /easf orro (1) yea�
� Pddress ot contra�n Dw� C ciy, sbb, and ZIP mde) �s ina p(ooaM �n cuestion:
eal pmperry � Mobile home (IC 644-7)
T�ing Eis ' Key num6er I legal descnption ( Recortl number Paga r,umber
a�-ll-la 301-�.� o(�-v,a8
LSIhe properry u5e0 atk occuped primanly br 0.5sessed valua of Ihe Wooerry as af Ma�ch 1, wrtert year (may rmt ezceed 5182,d30
hisRier rea'denw7 hiO�e� 65 CeduCim. a Sf60,000 Por Ne Pe� 65 Ciicurt Brazker Qedi�
� Yes ❑ No ��
Was ihe aOW� 65 yeara oi age or rtare on Dacember 31 d the year
Yes � No
Have you filetl for deductiom in any other courrty? — / If Ves. what wumy7
❑ �S I� "'�
IIWe certify under penalty of perjury Ihat the above and foregoing information is trve and correct and that the applicant was a resident
of Indiana and owner of the aforementioned properly on March 1, 20
� Sgnalure of aD7�M Addrass of eoolifant (numGwenC streat, ciy, sWte, antl Z/P mde)
l
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Sipnaturedeuthor¢e0 raeeritative Mdresso(aNhorizadrepresentaWe (numDeraMSLOOCciry,slate.a dLPcoOe)