Age_Roberts (2) c°"-' APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
l PROPERTY TAX BENEFITS 1
t 2o��
State Form 43708(R13/4-15) C o� n,n
�-' Prescribed by the Department of Local Government Finance `�law
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 CountyAuditor of the county where the property is located. •
Filing Dates: 1) Real Property:Form must be completed and signedby December 31 and filed or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured months .
before March 31 of the year the deduction is to be effective.
•
See reverse side for additional instructions and qualifications.
• Type of benefit request d lease check all that apply)
Over 65 Deduction from ASASessPrl Vail tion ❑ Over 65 Circuit Breaker Credit
Name of applicant(o ner contract buy-
2 0 L • C. 7_Ob
Is applicant th le legal or itable owner? if No,what is his/her exact share o ' rest? If owned with joint tenant or tenant in common,
indicate with whom
WI - IN No
c- 11 ' ' ��L
If name on record is differen th-n that of applicant,Indic .:•el< z, Do all joint tenants or tenants in common reside on the property?
❑ No
Name of contract seller NOV 2.a 2019 Has applicant owned or been buyinXYes
property under recorded
tV contract for at least one(1)year before claiming deduction?
,— ❑ Yes ❑ No
Address of contract seller(number and street,city,state,and ZI �� � Is the property in question:
If I GIBSON COUNTY AUDITOR Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district
Does'applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
$182,430 for Over 65 Deduction or$159,999[counting just the homestead site]for the Over
Yes El No 65 Circuit Breaker Credit.)
See reverse for details.
Is the applicant 65 years of age or more on DeceK
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? was the spouse's age at the time of death?
Yes ❑ No
. Adjusted gross income of applican , plicant and spouse,or
Yes ❑ NoIA
Have you filed for deductions in any other county If Yes,what county?
❑ Yes )(\çNo •
1/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 ZI code)
SE0 c� a P �, �-� of NA e. ..„.3
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Si na ure a thonzbd re representative Address of authorized representative (number and street,cl state,and ZIP cod 9 P p hs