Age_Douglas (2) �ae APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
r PROPERTY TAX BENEFITS
7 State Form 43708(R13/4-15)
Prescribed by the Department of Local Government Finance �--
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. , 1 1 j
INSTRUCTIONS:To be filed in person or by mail with the CountyAuditor of the county where the property is located. DEC 2 6 2018
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the following January 5.
2) Mobile Homes assessed under IC 5-1.1-7 or manufactured homes not assessed as real property:During fl)B lively 12 P 'withC
before March 31 of the year the deduction is to be effective. JTINbui W
See reverse side for additional instructions and qualifications. GIBBON COUNTY AUDITOR
Type of benefit requested(please check all that apply)
❑✓Over 65 Deduction from Assessed Valuation [✓r 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
7fOrge .
Is applicant the sole or equitable owner? If No,what is er exact share or interest? If owned with joint tenant or tenant in common,
indicate with whom
es ❑ 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?
0. Yes ❑ No
Name of contract seller Has applicant owned or been buying the property under recorded
contract for at least one(1)year before claiming deduction?
❑ Yes ❑ No
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
❑ Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
Pats-C.L_Q a t9 1-1>- (oo -coy Mt1,2ima-l-.
Does applicant reside on property? Assessed value of the properly as of current year assessment date(may not exceed
l�f S162,430 for Over 65 Deduction or S159.999(counting just the homestead site)for the Over
LIG Yes ❑ No 65 Circuit Breaker Credit.)
See 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 filed 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?
L < ❑ No
Adjusted gross income of applicant,applicant and spouse, or Source of Income
Have you filed for any other deductions? If Yes,what deductions?
❑ Yes ❑ No
Have you filed for deductions in any other county? - If Yes,what county?
❑ Yes ❑ No
WJe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
214.,( nJ/ nnaiL Be& to maCarthfr 2d ?2ince-t6x,TN blot
Signature of auhorized/e +presentative Address of authorized representative (number and street,city,state,and ZIP code)