Age_GriesemerErr
.tor.!.. APPLICATION FOR SENIOR CITIZEN couN"-alla=M;`'j'; • - •
PROPERTY TAX BENEFITS 11/'
'`'.'---. Slate Fonn 43708(R9/9-08)•
5 , f Proscribed by the Department of Local Government Finance r EP 8
2014
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. 7JnG/]Et'
INSTRUCTIONS: GIBBON COUNTY R
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property:During the twelve(12)months before December 31 of the year the deduction is to be effective.
2) Mobile Homes assessed under IC 5-1.1-7 or manufactured homes not assessed as real property During the twelve(12)months
before March 31 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Type of benefit requested(pleaw check all that apply)
Over 65 Deduction from Assessed Valuation ❑ Over 65 Circuit Breaker Credit
Name of applicant(owners contract buyer)
t Cie
Is applicant the sole legal or equitable owner? f No,what is his/her exact sham or interest? If owned with someone other than spouse,
����-,,��"""" indicate with whom
[)yes El No
If name on record is different`than that of applicant,indicate below
Name of contract seller(applicant must have been buying on contract at least one(I)year)
Address of contract safer(number and street,city,state,and ZIP code) Is the bproperty in question:
• Y'-TReal property ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
Is the property used and occupied primarily for Assessed value of the property as of March 1,current year(may not exceed$182,430
his/her residence? for Over 65 deduction,or$160,000 for the Over 65 Circuit Breaker Credit)
ire es ❑ No
was the applicant 65 years of age or more on December 31 of the year
\f
❑ Yes alo
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1,20 .
Sgnatu of applicant Address of applicant (number and street,city,state,and ZIP code)
Le ma 1. �tAt30 6'.
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZBIScode)