Age_Harbison (2) '"'" APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
e PROPERTY TAX BENEFITS
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\, StateForm by the ep3t0-15) TO53°
Vv\ I20 Ie`� Prescribed by the Department of Local Government Finance t �/ `ck
I
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS:To be bled in person or by mail with the CountyAuditor of the county where the property is located.
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/C 6-1.1-7 or manufactured homes not assessed as real property:During the
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indicate with whom
I Yes ❑ No
If name on record is differ nt th that of applicant,indf�'�elwb Do all joint tenants or tenants in common reside on the property?
1'ILu` J�1gpglll.. '),/ Yes ❑ No
Name of contract seller J^N 11
2019 Hasa applicant owned or been bu
FihJ L IJ ct y g the property under recorded
contract for at least one(1)year before claiming deduction?
LLL111 ❑ Yes n No
Address of contract seller(number and street,city,state,and ZIYI o e
✓MIs the property in question:
property
GIBBON COUNTY AUDITOR Real ro p p y ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number I Legal desolation of Record number Page number
MnceADV' • a6-\\-\2 iD4 -001 .0% -
Does applicant reside on property? Assessed value of the property as of current year asse sment date(may not exceed
$162,030 for Over 65 Deduction or 5159,999(counting just the homestead site]for the Over
❑ No 65 Circuit Breaker Credit.)
YesSee reverse for details.
Is the applicant 65 years of age or more on D m 31 of the year
Adjusted gross income of applicant, a licant and spouse, or Source of Income Amount of Income
applicant and joint tenants or tenants in common, as
applicable(For Over 65 Deduction, income may not exceed $
exceed S30,000 for individuals or S40,000 for married couples.). S
See reverse for details. TOTAL S 0.00
Have you filed for any other deductions? ,�\t, ,L1IIff Yes,what deductions? / 'w/\TC
IJJ�Yes ❑ No 1 J� (i / �i+` ' -1 �
Have you filed for deductions in any other county? "` Alo
LLtIf Yes,what county? { U❑ Yes
I/We 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) NA._
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`,dito,,x. b Po A Z0 s I�' / v - , 1 ov-c.t1-}e i 1�,t` 1 n
Signa ure of authorized representative Address of authorized representative (number and street,city,state,and Zl code)
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