Age_Wolfe ner a APPLICATION FOR SENIOR CITIZEN COUNTY / t0 ENSHS ;ice
? PROPERTY TAX BENEFITS j.
� l State by
R13/4-15)
•°%a,: Prescribed Dy the Department of Local Government Finance •
Filelvt!rk
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.G I B S 0 N COUNTY AUDITOR
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and tiled or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 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. C I` P ICACIO
Type of benefit requested(please check all that apply)
Over 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
Comex- 1 L,J O 1' e.
Is applicant the sole I equitable owner? „, ....at share or interest? If owned with joint tenant or tenant in common,
indicate with whom
Yes ❑ No
If name on record is different than that of applicant,indicate below Do all joint tenants or tenants in common reside on the property?
❑ Yes ❑ No
Name of contract seller Hasa applicant owned or been bu
ying the property under recordedcontractact for at least one(1)yearr before claiming deduction?
❑ Yes ❑ No
Address of contract seller(number and street,city,state,and ZIP code) Is the property' question:
Real property ❑ Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
t cLor1 a112 — t -300tpoa `kUt4-0
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
S182,430 for Over 65 Deduction or 5159,999[counting just the homestead site)for the Over
LI No 65 Circuit Breaker Credit.)
YesSee reverse for details.
Is the applicant 65 years of age or more on December 31 of the year Applicant's date of birth(month,day year) If tiled by a surviving,unmarried spouse,what
prior to the year taxes are first due and payable? was the spouse's age at the time of death?
Yes ❑ No
Adjusted gross income of applicant, applicant and spouse, or Source of Income Amount of Income
applicant and joint tenants or tenants common, c
applicable(For Over 65 Deduction, incomemay may not exceed � 1�.-- S
S25,000;for the Over 65 Circuit Breaker Credit, income may not 5
exceed$30,000 for individuals or$40,000 for married couples.). .
See reverse for details.
❑ Yes ID No
Have you filed for deductions in any other county? If Yes,what county?
❑ Yes ❑ No
lIWe certify under penalty of perjury that the above and foregoing information is true and correct.
kSignature of applicant Address of applicant (number and street,city,statue,and ZIP code)/�
\(�) lC p�0c14 X o lO/ n (�.�e , VNr- �.r r� �/7(76
Signature of au orized representative Address of authorized representative (number and street,city,state,and ZIP code)