Age_MenyOAPPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
S , Sbte Form 43708 (R919-0e)
Prascnhed by ihe Deparimem of loral Govemmerit Financa
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tnformatiom m�tained in lhis daument is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC E1.L35-9. ��'B�y
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INSTRUC710NS:
Tobefiledinpersonor6ymailwRhfheCourrtyAuditavolthemuntywherethepope�tyislocated. GIBSONCOUNTYAUDITOR
Filing Dates: 1) Real Properfy: Dunng Ihe tweNe (72) mmths hefore December3l o/the year fhe tleduclion is to 6e eflective.
2J Mo6i/e Homes assessed urMer IC 61.1-7 or manulactured homes rwf assessed as real property: Dun� the Mshs (12J mmfhs
6e/we Marrh 31 of the year the deduGion is to be eflactive.
See ieverse side for additional insWCtions arM qualifications.
Type d benef.t repuested (pleasa rheck a9 fhaf aPdY)
er 65 Deduction 6om Assessed Valuation ❑ Over 65 Circuit Breaker Credit
Name of appGaM (owrrer a� cmt2d Wye�
1 ,\ �
Is avV��m the sde r equitahle tl No, what is his/her anad sture or intarasl7 It owneE with mmeone other than spouse,
inditate with whom
es ❑ No
rc�wne on remd "a aitlara(rt ihan ihat d appfifant ��dkaie bebx
Name a mnar� seoer (appticanf musl nave eeen nuyiry on c«nraa at �east orre (f) yeaq
Pddrass d contrad wller (numDer arid sbee4 ti�: sbfe, aM ZIP code) Is lhe pioperty in ques�ion:
I YQApaI pmperty � Mobile home (IC 67-7-�
�r�
Taring d'¢irict Key number / Legal desuiption Record numbar Page number
-1 `-c�� - b - .e��do -'b
I5 the ryopeM �� arW ompied primarity lor Assessed value ol �he poperty as of March 1, wrrant yaar (may rrof exceeC E7B2,130
Idvher residenwT lorO�.er 65 tletludia; ar E160.O00 lor flre Ovar 65 Cimul &eal�er CrediQ
es ❑ No
Was lhe appficarit 65 years o! age a rtwe on December 31 of the yaar
r�a yw rdea f« e�y anar daa�sa ir �, �i aad�m�?
�Yes � No
Hava you filed far deductlons in anY other murity? If Yes. what oourrty4
❑ Yes �o
IIWe certify under penalty of peryury that the above and foregoing information is true and corted and lhat the applicant was a residenl
of Indiana and owner of the aforementioned properly on March t, 20 _
Signaturaofapq'raM Pddressofappfxant (nwnbera�dsboeLaN.s�fi.andZlPmde)
�m a� $ �-�� $� a.�bsfa.d�-. IN �11�3
natufe o( a or¢aC rapresantaliva Pd ress ot auUror�d raprasentative (nvnbor aM sLOef. rity, staf0. end LP code)
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