Age_Weiss (2) •
e -v; APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�• PROPERTY TAX BENEFITS
s
\- ,yr/ State Form 43708(R73/4-15)
:�:/ Prescribed by the Department of Local Government Finance
Fil 5rk
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. I
INSTRUCTIONS:To be filed in person or by mail with the County Auditor of the county where the property is locateAp R 1 8 2019
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 proper/p•During a re-{f2)months
before March 31 of the year the deduction is to be effective. J7,yl
See reverse side for additional instructions and qualifications. GIBBON COUNTY AUDITOR
Type of benefit requested(please check all that apply)
XOver 65 Deduction from Assessed Valuation Z Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
)0—i-4D 2 /4j)
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 different than that of applicant,indicate below Do all joint tenants or tenants in common reside on the property?
❑ Yes ❑ No
Name of contract seller Hasa applicant owned or been buying theproperty
undo 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 propertyrope/ in question:
[Zj Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description 1 Record number Page number
/i ia(c. -/F-34- Lib y- coo. 3o5- o09
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
❑ No 65 Circuit Breaker Credit.)
YesSee 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?NY
was the spouse's age at the time of death?
NYes ❑ No —
Adjusted gross income of applicant,applicant and spouse, or Source of Income Amount of Income
applicant and joint tenants or tenants in common,as .
$25,000;for the Over 65 Circuit Breaker Credit, income may not
exceed$30,000 for individuals or S40,000 for married couples.). S
See reverse for details. TOTAL S 0.00
Have you filed for any other deductions? If Yes,what deductions?
[Yes ❑ No �S
Have you filed for deductions in any other county? If Yes,what county?
❑ Yes No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
i Signet of applicant ��J Address of applicant (number and street,dry,state,and ZIP code)
,if/ 4//� l 7Oy S. 1 (i�� ..a S s-7% DT t# c-s76, 3 y
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)