Age_Johnson (3) ZeAPPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
t PROPERTY T AX BENEFITS
State Form 43708(R9/9-08)
'.i. Prescribed by the Department of Local Government Finance D
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35- ` Mark
INSTRUCTIONS: 1111 Ill
To be filed in person or by mail with the County Auditor of the county where the property is located. S 'n
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the year the deduction is to be enectNe.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as rea mperty:During e twelve(12)months
before March 31 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Type of beneft requested(please check all that apply)
® Over 65 Deduction from Assessed Valuation ['Over 65 Circuit Breaker Credit
I
Name of applicant(owner or contract buyer)
Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? If owned with someone other than spouse,
indicate with whom
❑ Yes ❑ No
If name on record is different than that of applicant,indicate below
Name of centred seller(applicant must have been buying on contract at least one(I)year)
Address of contract seller(number and streek city,state,and ZIP code) Is the property in question:
Gil-�fJ i
al property ❑ Mobile home(IC 6-I-1-7)
Toting Q�Stl� / Key number/Legal description Record number Page number
\/Y///) 07s-ia- o5-t 70 /. Y30- oQ j
Is the property used and occupied • city for Assessed value of the property as of March 1,current year(may not exceed 5182,430
his/her residence? for Over 65 deduction,or 5160,000 for the Over 65 Circuit Breaker Credit)
❑ Yes ❑ No
I
Was the applicant 65 years of age or more on December 31 of the year Applicant's date of birth(month.day,year) If filed by a surviving,unmanied spouse,
prior to the current year? what was the spouse's age at the time
__ _ _ -- ❑ Yes ❑ No /61-79-A/ of death?
Adjusted gross income of applicant, spouse,and any - _
Have you filed for any other deductions? If 1§s,what deductions?
Yes ❑ No cL 5
Have you tiled for deductions in any other county? If Yes,what county?
❑ Yes No
I/We certify under penalty of perjury(hat the above and foregoing information is true and correlct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1,20 I
•
S' n ure of appfrdrd Address of applicant (number and street,city,state,and ZIP code)
,9 gym— �95i r ,�e),. isv.�r
Signature of authorized/presentative Address of authorized representative (number and street,city,state,and ZIP code)