Age_Larson APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
litivis State Form 43708(R15/1-20)
e'.\-------4- Prescribed by the Department of Local Government Finance .-sen 02: - 2-0 2-3 •imp
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 of benefit requested(Please h k all that apply.)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of a cantd.owner or con t uyer)
1-,ivAii•N
Is appli the s
"able owner. If ,what is his/her exact share or interest? If owned with Joint tenant or tenant In common,indicate with whom.
1]Yes El]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?
EI Yes Li No
Name of contract seller Has applicant owned or been buying the property under r 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 th property in question:
Real property 111Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
0 1 - .
•X-05--31-1100-001- 14/— 0 •
Does applicant reside on pr ? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
s 0 No [counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all 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 ag or more on Decem er 1 of the year Applicant's date of birth(month,day,year) If filed by a,surviving,unmarried spouse,what was
rYe
prior to the year taxes are first due and payable?
• Yes E No i --9•6.La -z•I c,LI•s--- the spouse s age at the time of death.
Adjusted Gross Income(AGI)of applicant,appli a t and spouse,or applicant Source of Income Amount of Income
and joint tenants or tenants in common,as applicable(For Over 65 Deduction,
AGI may not exceed:(1)$30,000 for individuals who filed a single return;(2) 7—XJ 2-- 1 $ 3t pR--t-t
•$40,000 for individuals who filed a joint return;or(3)$40,000 for individuals and all
others that share ownership as joint tenants or tenants in common.For the Over 65 2 2 2- • $ 2-1 , '
Circuit Breaker Credit,AGI may not exceed:(1)$30,000 for individuals who filed a
single return;or(2)$40,000 for individuals who filed a joint return with the /
TOTAL $
individual's spouse.)See reverse for details.
Have you filed for any other de uco: ns? If Ye what deductkons?
Yes Li No tt V\--Q()\. .1
Have you filed for deductions n an other ou y? If Ye ,what county?
N
Lives No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant X
A"fefddi1J Date(month,day,year)
Addr of applicant (number and stre t,city,state,and ZIP code)
\33q N sg- 6C K..cic6)--
Signature of authorized representaeve Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of Cor ito Date(month,dayvear)
FILED ...
MAR 2 2023
Yhi.autze a.,
GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer