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-,+` "P'4• APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
lit .-- PROPERTY TAX BENEFITS
1.11.11160,/• State Form 43708(R19/7-25) C..... ..
'•.• Prescribed by the Department of Local Government Finance if' 1\ f ZPiCrA-01\. 1Ur)
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
Instructions To be filed in person or by mail with the county auditor of the county where the property is located_
FilingDate Form must be completed. signed, and filed with the county auditor or postmarked by January 15 of the calendar year in
which the property taxes are first due and payable
See reverse side for additional instructions and qualifications
Type of Benefit Requested (Please check aiLlbal apply) f -1
D liver 65 Credit Dover 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer) Telephone Number Email Address
.e_1\ 4- ka \c‘ L‘ N ' ( C (' . D\ ) iQ7-1 - 0 9 o•
Is Applicant the Sole Legal or itable Owneer9 If No, What is Applicant's Exact Share or Interest? It Owned with Joint Tenant or Tenant in Common, Indicate with Whom
DYes ❑No
If Name on Record is Different than Applicant, Indicate Below Do Ali Joint Tenants or Tenants in Common de on the Property?
es ❑No
Name of Contract Seiler Has Applicant Owned or Bought the Property Under recorded Contract
for at Least One(1)Year before Claiming Cre��
0:1Xes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code) Is the Property in Question:
Real Property ❑ Mobile Home(IC 64.1-7)
TKg Distnct Key Number/Legal Description Record Number Page Number
•ViZ-Ik t1 Cr \ C' • .k_C) -.t-- - 'el - 1 0 - 00 . 1 --(0'aiR .
Did Applicant qualify for the homestead standard deduction in the preceding year(or was applicant mamed at the time of death to
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead property in the immediately ❑v Yes ❑ No
preceding calendar year)and does Applicant quality for the homestead standard deduction in the current year?
Is the Applicant 65 Years of Age or More on December 31 of the Year Prior to the Year Taxes are First Due 8 Payable? 1+e1 Yes ❑ No
Applicant's Date of Birth (month, day,year) ff Filed by a Surviving, Unmarried Spotse,What Was the Spouse's Age at the T r ne of Death?
`l — Q1, 5r- . ti. 0 - - \ a-[ 1 ir) ._ -
Source of Income Amount of Income
Adjusted Gross Income (AGI)of applicant, applicant and spouse, or applicant
and joint tenants or tenants in common. as applicable (For Ow' 65 Gredi AG!may not exceed. (1) $60,000 for individuals who filed a single return, (2) 5 70,000 for 4 0
1 ::1
indrviduals who filed a joint return;or(3)$70,000 for individuals and a1 others that10C=led
q
share ownership as joint tenants or tenants in common For the Over 65 Circuit � 1.4
Breaker Credit, AG!may not exceed' (1)S60,000 for individuals who Ned a single a
return, or(2)$70.000 for individuals who filed a pint return with the rxdividl.iars CO(,�1C
1 .
spouse.)[Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted]See reverse for details. TOTAL S
UWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature,.o/Appl nt r Date (month, day, year)
c,_) 6
X 4 , - ate ,
Address of . be strV ` L■et city stat and ZIP •••:
Appli
i .)\--k-nL._- Lt4tp 1" Q
Signature of Authorized Representative Date (month, day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code)
ire of County Auditor Date (month, day, ye
FEBELL ED
D - f - .
12 2026
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DISTRIBUTION: Original - County Auditor, File-Stamped Copy - Taxpayer
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(31
GIBSON COUNTY AUDITOR
APPLICATION FOR SENIOR CITIZEN
;6... . „ PROPERTY TAX BENEFITS
SfaIB Form 43708 (R9 / 9-08)
•� -� � Presaibed by the Oapartmem of Local Go�emmeM Finance
Infwmatiwi mntained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 anC IC 61.135-9.
COUNTY TOWNSHIP YEAR
OCT 1 9 2012
INSTRUCTlONS:
Tobefiledinpersonor6ymailwifhtheCountyAudRorolthewuntywhe�efhepropertyislocated. C.�,�Y�,.,-�--
Filing Dafes: 7J Real PmpeRy: Dunrn� the tweNe (72) montfis be(ae Decem6er 31 07 fhe year the deduction is to 6e eRecliva��
2) Mo6ile Homes assessed under IC 51.1-7 or manWactured hwnes rrof assesser/ as real�;�ND�l�rg �F e fwelreYi�r2onfhs
be/ore Malch 37 ollhe yeer the tleduction is lo be eflective. 7 AUUI ft
See reverse side fa atldifional insWdions antl qualrfications.
Typa ol benef.t raquested (pleaso rheck a0 fhat appy)
� Over 65 Deduction 6om Assessed Valuation �Over 65 Circuit Breaker Credil
Name ot appfiranl (owrrer a+cmt2ct b�yeQ
%(���-�� � �o..
k appfi�anl the sde legal or aquitaWe ovma(/
❑ Yes ❑ No
H nama on recorE is diHerent than Nat of eppGpnt, iM
Nama of miriact seDer
M
orre (fl Yea7
ifrtaresl7 If owned vnih saneone other Ihan spousa,
iMirate wi�h wtrom
AAtlrasa d mntrad mVar (mxn6ei aM sbea4 �: 56fe. ariC LP code) Is Ne pmpe�ty in Questwn:
� Real property ❑ Mobile home QC 614-�
7y�' ��� Key number / Legal descnWion Ramd number Page number
r
6 -I z-a7-io� -ooa . �o
49 the pmpeM used aM occupied primariy for Aasessetl value ot lhe praperty as ot March 1, curtent year (may lrot exceed S1B2,430
hisRiar �eSiCenm7 1or O�er 65 Cetlucliwi, or 5160.000 hr Ne Over 65 Ciinul Breaker Cradi�
�Yes ❑ No
Wav tha appWartl 65 years o er 31 0( the year �
prbr lo tlie airtent yea
��Yes ❑ No �t/
c
Adjusted gross income of applieant, spouse, and any
individuals sharing ownership (For Over 65 deduction, income
may nof exceed 825, 000: for the Over 65 Circuit 82aker Credif,
income may rrot exceed 530,000 /or individuals, or 540.000 for
married couples).
Hava you (JeC For arry olher deducGrns7
liave yw rum ror aeductions in ar�y aner
� Y�es ❑ No
z
❑ Yes � No
iTS dale of birth (monlh, dax yearJ If filetl try a surviving, �nmartietl spousa,
p�� 5-- 3� wha� was Ihe spouse's age a� Iha Iime
! of death?
� - - $ %
Source of Inwme Amou�rt of Income
/o�o _ ,�o�i � �3 ��y
$
TOTAL $ 0.00
If}§s.whatdeductiorts?
S rnf
���.�� �� �
IlWe cerlify under penalty of perjury that lhe above and (oregoing infortnalion is true and correct and that ihe applicant was a resident
of Indiana and owner of the aforementioned property on March i, 20 _
,
Signalura ppwant � n Addressofa001iram (munDerarMstreeCtly.sbte.aMZlPCOde)
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(
Address of aWhorimd represenfative
sWet,aty,5ato,endLPcade) ,�7 ��� a