Age_Mabe APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP I YEAR
'" PROPERTY TAX BENEFITS yT
Pie Stale Ferro O?g9(Pin H-157 �� f
Prescribed by he Department of Local Government Finance
File Mark
Inionna0on contained in Ws document is CONFIDENTIAL pursuant to IC 6.1.1-35-9.
MAR 162016
INSTRUCTIONS:To be Pled in person or by mai wish the County Auditor or the county wirers the properly is located.
Filing Dales: 1) Real Properly Form must be completed and signed by December 31 and Ned or postmarked by the following January
2) Mobile Homes assessed under IC 5-1.1-2 or manuladused homes not assessed as real properly:During the Melee 1 • lbs •I .,
before Marro 5 t W the year the deduction is to be effective. G IBSON•COON TY�q U DI TO R
See reverse side for additional instructions and qualifications.
Type bl benee requested(please check a that apply)
® Over 65 Deduction fromAssessed Valuation L.Over 65 Circuit Breaker Credit
. Name cl applcanl(owner or centred buyer)
Ji Ph Ill tI- A. in4,5r c.Eie)Eff' d(-LE /y'�Ac t
Is apptceet the sole lkgd or equitable owner? If No,woe owner e.ecl share or Merest? Row ad wi wowmenent or lee sat In common.
Inte IV Yes ❑ No
, if name on record Is different then that of appkant.indicate below Do all Ohl tenants or tenants In common reside on he properly?
Wyln� Yes ❑ No
Name of conned seller contra It ear nal lone(1)veer bibleelcaaning eebrclbnrtd-d •
g Yes ❑ No
Address of contract seller(number end shed ely,stalle.and ZIP code) Is ars properly he question:
jii Real properly ❑ Moths home(IC 5.1-1-7)
Taring district Key number!le pal duscalpinn Record number Pepe number
1)(4x 01G -/2—a" o/- oa/ /3 -0022
Does a icant reside on pronely?
❑ Yes ti" No
Time you filed for deductions In any other county? If Yes.what county? .
❑ Yes ILI No
IANe certify under penalty of perjury that the above and foregoing Information Is true and correct.
Signac t.pleant address of•ppaeant(number and street,cky,state,end Idkcode)
C., .1/21c 30 3 G /U''(-w 4 'Sr
-vat a of authorized re preenta lee Address of euhodced representative(number end sued,city slate and ZIP code)