Age_Fulton (2) .M"-rAk APPLICATION FOR SENIOR CITIZEN
,�e. PROPERTY TAX BENEFITS COUNTY TOWNSHIP YEAR
"' 1State Form 43708(R15/1-20)
. ;;r Prescribed by the Department of Local Government Finance
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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. MAR
Filing Date: Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the follow 4 2021
January 5 of the calendar year in which the property taxes are first due and payable. l��
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See reverse side for additional instructions and qualifications. /hi-cfezd &._t1 .rirt4)
GIBSON COUNTY AUDITOR
Type of benefit requested(Please check all that apply.)
ver 65 Deduction from Assessed Valuation III Over 65 Circuit Breaker Credit
Name of applicant(owner or contr ct buOyer) 4
Is applicant the sole legal or equitable owner? I•o,, t i ,�its/her exact share or interest'? If owned with joint tenant or tenant in common,indicate with whom.
11%1Yes ❑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 III No
Name of contract seller Has applicant owned or been buying the property under reco ed contract for
at least one(1)year before claiming deduction? yes El No
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question: ''
Real property ❑Mobile home(1C 6-1-1-7)
Ta ' g dist' t Key number/Legal description Record number Page number
4- m fiL aL- 19-18-/Oi-Cot AA:,
Does applicant reside on o erty? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
Yes D No (counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999 fall Indiana real
property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)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 was
prior to the year taxes are first 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, hat deductions? ///���
Yes ❑No Q S k�d i 1 CI( r 9 a .v_
Have you filed for deductions in any other county? If Yes,what county?
ID Yes ❑N)
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Sigicay.6 of applicant .1 / �`� Date(month,day,year)
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ZIP Address p li nt berand str =t,cTy,state,and de) )-it_
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Signature of authorized representativ Date(month,day,year)
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ddress of authorized representative (number and street,city,state,and ZIP code)
Si nature o ounty Auditor Date(month,day,year)
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MAR 4
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GIBSON COUN•t • . .%= -. C
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer