Age_Simmons S`"'".oa APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
a- PROPERTY TAX BENEFITS
i _
\. --f State Form 43708(R13/4-15)
\ni: Prescribed by the Department of Local Government Finance
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
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.
Type of benefit requested laease check all that apply) ,,`
-Ayer 65 Deduction from Assessed Valuation I Y Over 65 Circuit Breaker Credit (,30}11 I J\1
Name of applicant(pipe -orr ntract buyer) �J�\
iil01\a el 4 k 4c t S ryko As "
Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,
indicate with whom
Yes ❑ No
If name on record is differ t th that of applicant,indicate below Do all Joint tenants or tenants in common reside on the property?
Yes ID No
Name of contractseller Has applicant owned or been b g e property under recorded
contract for at least one(1)year befor claiming deduction?
❑ Yes ❑ No
Address of contract seller(number and street.city,state,and ZIP code) Is the ope in question:
Real property ❑ Mobile home(IC 6-1-1-7)
Taxing cl Key number/Legal description Re d number Page number
�, � . art2-01 - iO4 oo2t-t86o28 .
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
$162,430 for Over 65 Deduction or$159,999(countin jus • ad site)for the Over
65 Circuit Breaker Credit.)
❑ Yes ❑ No
I
See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
JAN 8 2019
Adjusted gross income of applicant,applicant and spouse, or Source of Income Amount of Income
applicant and joint tenants or tenants in common, as - I
applicable(For Over 65 Deduction, income may not exceed p�
S25,000;for the Over 65 Circuit Breaker Credit, income may not GIBSON COU Y AUDITOR
exceed 530,000 for individuals or S40,000 for married couples.).
See reverse for details. TOTAL S 0.00
Have you filed for any other deductions?
❑ ��.rn�
YesNo H\J �11 t 1e
•
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature applicant Address of applicant (number and street,city,state,and ZIP cod
oakialfd I I C E 3n
Si a re of authorized reprtive Address of authorized representative (number and street,city state,and ZIP code) f