Age_McGillem a� APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
A:-. PROPERTY TAX BENEFITS
\5E i' State Form 43706(R13/4-15) ( ` /4) �`Ay\ IQ
\ru: Prescribed by the Department of Local Government Finance v ' 11
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 lease check all that apply)
Over 65 Deduction from Assessed Valuation ❑ Over 65 Circuit Breaker Credit
Name of applicant( vner or tract bu er)
K l fug c illein .
Is applicant the sole legal itable owner? If No,N at is his/her exact share or interest? If owned with joint tenant or tenant in common,
indicate with whom
Yes ❑ No gp @gip
If name on record is differ t than at of applicant,indicat lo� ® l y Do all joint tenants or tenants in common reside on the property?
g}}�JJJ �LJ Yes ❑ No
Name of contract seller MAH 0 8 2019 Has applicant owned or been buying a operty under recorded
contract for at least one(1)year before aiming deduction?
of . S ❑ No
Address of contract seller(number and street,city,state,and ZI Is the property in question:
GIBSON COUNTY AUDITOR gyp/
Real property ❑ Mobile home(/C 6-1-1-7)
Taxing distrii i At Key number/Legal description Record number Page number
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
5182,430 for Over 65 Deduction or 5159,999[counting just the homestead site)for the Over
IeS NO 65 Circuit Breaker Credit)
See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
Adjusted gross income of applicant, applicant and spouse, or Source of Income Amount of Income
applicant and joint tenants or tenants in common, as
S25,000;for the Over 65 Circuit Breaker Credit, income may not •
exceed S30,000 for individuals or S40,000 for married couples.). IS
See reverse for details. TOTAL I S 0.00
Have you filed for any other deductions? ,,{{ ,If1Yrls,what deductio`�s?
jy Yes ❑ No 1 -113]r _ \ J &3ffg .
Have you filed for deductions in any other county? If Yes,what county?
❑ Yes n No
IANe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Addressdr of applicant (number and street,city,state,and ZIP code)
4atittunt, Q m✓ D� s e. g 1 i'n - --a-+O
of authorized representative Address of authorized representative lumber and street,city,state,and ZIP code)