Age_Wiserr
'"'". APPLICATION FOR SENIOR CITIZEN COUNrv TOWNSHIP ven�t
_ , PROPERTY TAX BENEFITS
Sfate Fwm 43708 (R9/ 4-0e)
•� y, f Prascnbed Cy Ne Departmerit ot Laal GovamneM Finance
FI
Infortnatiom m�tainetl in this dowmenl is CONFIDEN7IAL pursuant to IC 61.1-12-9 and IC 6-1.1359.
INSTRUCTIONS:
To be filad in person or by mail with the CountyAudifor of the munty where the poperty is located. O C T 2 5�Ot�
Filing Dafes: 7) Real Property: Dunrx� the tweAre (12J maRhs before December 31 0l the year fhe tleduction is to 6e elfec�lirve.
2) Mobile Hwnes assessed uiMer IC 6-1.1-7 ormanulacturetl homes rrot assessed es real property.� �nrg�the lwe (C1�\months
be/ae Maafi 37 of fhe }rear the deduction is to be efFective. V
SeereversesideforadddionelinsWdionsantlqualifice6ons. GIBSON COUNTY AUDITOR
TYGB ��neH reQuaSatl (please fieck aID Ihat apply)
�65 Deduction from Assessed Valuation � ❑ Over 65 Circuit Breaker Credit
Name of apptirant (owrrcm w contrac( G�ye�
r
Is app carit Ne sde lepal or apuilaWe owne/? If No, what is his/her exact share u iriterest7 H avned with mmeone other than spoum,
,�/ i�Mita�a xi�h whom
j� Yes ❑ No
It name m racwd is d'MereM Nan that o(app5fant �ndirete bebx
Nama of mntrdd se0ar (app�xant must have Geen b�ryvg on cm12d af leasf one (1f yea�
Pddress ot mntrarl mller (numDer aM sbee4 �Y. sFab. aiM LP coda) Is the pmparty in question:
� Real property � Mobile homa (!C 6-1-1-�
7y�' �(�( Keynumber/legaldescriplian RecoNnumbar Pagenumbe�
- -�-y .� - 6a
Lv Ihe poperty usatl and xwpied ' 'ly for Assessed value of iha pmOeAy as af March 1, wrtent year (mny imt aresed E782.430
his/ner rasiden�»T lorOre� 65 dedudian, ar S1fi0.000/or No Ovar 65 Circ�it BroalafCred�
❑ Yes ❑ No
Was tha appbrar�t 65 years ot ape u more on Oacember 31 oF 1ha year
Mave you filed fw arry other Ceductions? It 1§s, what tled�ctionst
�Yes ❑No
Have you fJed (or deductions in any other wunry? If Vas, what courily?
� Yes ❑ No
IlWe certify under penalty of perjury that the above and foregoing information is W e and wrtect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
SignaW�eo(appfra'rt Addressofappliram (num0erandstreet,dry.sbfn,andZlPcode)
� 3 0�l S2�.T'i
Signai W authwrzad raprasantative �ess of au�horimd taprewnfative (nwnbvra�sGOaf, cify, state, and LP codo)