Age_Hopkins ""v APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
°e )30� a,01`t
r State Form 43708(R13/4-15) )NY-1
/o:'� 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. /p�c`^
INSTRUCTIONS:To be filed in person or by mail with the County Auditor of the county where the property is located. � '3SJ •
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 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. /'� t _ /�/•
See reverse side for additional instructions and qualifications. (�ir`�'p�7�\ (�
Type of benefit requested/(please check all that apply)
0 Over 65 Deduction from Assessed Valuation ❑ Over 65 Circuit Breaker Credit
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Name of applicant(owner dr,contract buyer)
_vt t ��k)i)s .
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
A
If name on record is different than that of applicant,indicate below Do all joint tenants or tenants in common reside on the property?
F !g LED ❑ Yes ❑ No
Name of contract seller ���LLL���JJ/���JJJ Has applicant owned or been buying the property under recorded
contract for at least one(1)year before claiming deduction?
MAR 1 5 2019 ❑ Yes ❑ No
Address of contract seller(number and street,city,state,and ZIP code) ,///1( �
Is the property in question:
aim
❑/ Real property ❑ Mobile home(IC 6-1-1-7)
GIBSnN COUNTY AUrJfTlIR '
Taxing district Key number/Legal description Reinrd number I Page number
• a6-12-c1-LAO\-oo2 .5y8- v3 .
Does applicant reside on properly? 17 Assessed value of the property as of current year assessment date(may not exceed
S 182,430 for Over 65 Deduction or S159,999(counting just the homestead site]for the Over
0 Yes ❑ NO 65 Circuit Breaker Credit.)
r t 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? \ / t .Q I' was the spouse's age at the time of death?
Elves ❑ No lZ• Z p' J`k
Adjusted gross income of applicant, applicant 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 g
S25,000;for the Over 65 Circuit Breaker Credit, income may not ` (, V
exceed S30,000 for individuals or S40,000 for married couples.). Ilif��I'J• �vttJJll 1 f g
See reverse for details. L1 1 • TOTAL g 0.00
Have you filed for any other deductions? If Yes,what deductions?
Res ❑ No �\*ItCa-- , \
Have you filed for deductions in any other county? \ \ _ If Yes,what county? V u
❑ Yes ft No
/ 1
r 1
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)
Signature of authorized representative✓ Address of authorized representative (number and street,city,state,and ZIP code)