Age_Dodge .04 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
y a PROPERTY TAX BENEFITS
a I State Form 43708(R14/10-17)
`1' Prescribed by the Department of Local Government Finance Gibson
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/C 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)
Lawrence& Patricia Dodge
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 El 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? ❑■Yes ❑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/Legal description Record number Page number
Patoka Town 26-04-24-302-000.351-020
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
Yes ❑No (Seecountingrevejseustfor det the homestead site)for the Over 65 Circuit Breaker Credit.)
❑ .
Is the applicant 65 years of age or more on December 31 of the year
Adjusted Gross Income(AGI)of applicant,applicant and spouse,or applicant
Have you filed for any other deductions? If Yes,what deductions?
❑■Yes ❑No Homestead
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.
Signature of applicant Date(month,day,year)
12/4/19
Address of applicant (number and street,city,state,and ZIP code)
602 N. Main St., Patoka, IN 47666
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)
/m 12/4/19
FILEt
DEC 042019
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer GIBBON COUNTY AUDITOR