Age_Powers R•'. APPLICATION FOR SENIOR CITIZEN
COUNTY TOWNSHIP YEAR
a PROPERTY TAX BENEFITS �y 1 �� ��
'. State Form 43708(R15/1-20) t /� �'d�
''ate -fir"' Prescribed by the Department of Local Government Finance \\J\
2,1
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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.
See reverse side for additional instructions and qualifications.
Type of benefit requested(Pleas chec all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of pplic nt p(o�wrnne1r or con qc r) �1 To -��
`Y 1 `/ 1 If owned with joint tenant or tenant in common,indicate with whom.
Is appli he sole le a owner? `If No,what is his/her exact share or interest?. I
Yes ❑No
Do all joint tenants or tenants in common reside on the property?
If name on record is different t n that of applicant,indicate below. ❑Yes ❑No
Has applicant owned or been buying the property under recorded contract for
Name of contract seller at least one(1)year before claiming deduction? 0 Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is t roperty in question:
eal property ❑Mobile home(IC 6-1-1-7)
Key umbgr{,Legdesciptjon� �� „^ �y _ 1-5- I Record number Page number
Taxing district 1 \--(0) (_�l O OV `�
Does applicant reside on p e ? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
es ❑No (counting just the homestead site)for the Over 65 Circuit Bl ed for aril re ewer b 2 Jan See reverse nd3.1t9.169
$19 9,999 fall Indiana real
property]for the Over 65 Circuit Breaker Credit initially app
Is the applicant 65 years age r more on Decem r of the year Applicant's date of birth(month,day,year) If filed
spouse by a,ss age intg,unmarried t aie de t spouse,what was
prior to the year taxes are first d and payable? Yes ❑No C^12..•1-�•S S-- �--g•S}
Amount of Income
Adjusted Gross Income(AGI)of applicant,ap scan and spouse,or applicant Source of Income $ ��
and joint tenants or tenants in common,as applicab (For Over 65 Deduction, /) -ti\� +
AGI may not exceed:(1)$30,000 for individuals who filed a single return;(2) C C/�✓ ! �' �'
$40,000 for individuals who filed a joint return;or(3)$40,000 for individuals and all W -•,-
others that share ownership as joint tenants or tenants in common.For the Over 65 G ,
Circuit Breaker Credit,AGI may not exceed:(1)$30,000 for individuals who filed a TOTAL $
single return:or(2)$40,000 for individuals who filed a joint return with the
individual's spouse.)See reverse for details.
Have you filed for any other de u ons? If Y what deductions?
Yes ❑No ,�
Have you filed for deductions in a\+Y other u y? If Yes,whatcounty?
❑Yes �o
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Af.......101,44.--
AddressDate(month,day,year)
� Sign ure of applicant /'J /� /�✓ �� /.`�.,C�'-t',�--- L.-1�-s��(l7 of applicant (number and street,city,state,and ZIP code)
Date(month,day,year)
Signature of authorized representative
Address of authorized representative (number and street,city,state,and ZIP code)
q 1 l date(month ay, e� �n '
Signatu n A it 1 G.-
-' FILED JI
DEC 2 9 2//0__21
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GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer