Age_Beard �*�'. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
yr,�f� PROPERTY TAX BENEFITS '�F'1
.\ma ., State Form 43708(R15/1-20) /V'y 3OVN , '•s-' 2-1
1' 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 Date: Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the following
January 5 of the calendar year in which the property taxes are first due and payable. �(� �
- _/ "'
Over 65 Deductio ssessed eeeV^^-alluation ver 65 Circuit Breaker Credit
Name of a 'ca ((o ner or co ct b�gij \ I;_`n: �
1 in v Lf(J� CCCIII //////
Is applicant the sole legal or equitable owner? If o,wha If owned with joint tenant or tenant in common,indicate with whom.
Elves ❑No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common resid • the property?
VA Yes ❑No
Name of contract seller Has applicant owned or been buying the property under -liri ed contract for
at least one(1)year before claiming deduction? �1 Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) I t e property in question:
Real property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
Q 9Z-12-08 - 3ot-co3_2 = (0-2.-2
Does applicant reside on p ? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
[taunting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
Yes ❑No property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years age r more on December 31 of the year
individual's spouse.)See reverse for details.
Have you filed for any other deductions? If Yeg,yvh�at d ductions? �1_C \.
❑Yes No r}/ ..S QL` Y 030 1,
il-
Have you filed for deductions in any othe u ? If Yes,what county?
CIYes No
[ . •
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
SignatV appl cant .�.p . •'�' Date(month,dT,,yrr)z, ( '"1 _-.. 2,...'
Al �yC�JC. • 41Lt.LC.� \\ f C/"
Address of applicant ( ber ands eet,city,state,an Z codek \�/ �� �� -
Si\ e CA 1.‘
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of ounty r- Date(minth,iy,e2yeaz......r) 1 f -
'f'�1FILED ��
NOV 2 2 2021
7)2,,,,lizze & .14- ,4;nd.)
GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer