Age_May (2) 4, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
L•'f State Form 43708(R14/10-17)
;4.4 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.
INSTRUCTIONS: To be filed in person or by mail with the County Auditor 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 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(Please check all that apply)
❑Over 65 Deduction from Assessed Valuation ❑Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
Charles & Mary May
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 Has applicant owned or been buying the property under recorded contract for
at least one(1)year before claiming deduction?
Oyes ❑No
Address of contract seller(number and street.city,state,and ZIP code) Is the property in question:
❑Real property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number I Legal description Record number Page number
Haubstadt 26-19-31-304-000.255-009
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 S159,999
['Yes No Iceunting ust the homestead site)for the Over 65 Circuit Breaker Credit.)
❑ 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 Ned by a surviving,unmarried spouse,what was
prior to the year taxes are fast due and payable? ['Yes El No the spouse's age at the time of death?
Adjusted Gross Income(AGI)of applicant,applicant and spouse,or applicant
Have you filed for any other deductions? If Yes,what deductions?
['Yes ❑No HS, MORTGAGE, VETERANS
Have you fled for deductions in any other county? If Yes,what county?
Lives ['No
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Date(month,day,year)
77114141-4 /t . 05/14/19
Address of applicant (number and street,city,state,and ZIP code)
300 E. Gibson St., Haubstadt
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of County Auditor Date(month,day,year)
-14-L,.1/4� a_If 05/14/19
FILED
MAY 14 2019
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer ova
GIBSON COUNTY AUDITOR