Age_Davis (5) APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
oNlitit„.7./IN/ State Form 43708(R15/1-20)
..:-.,..,-,:y Prescribed by the Department of Local Government Finance TOi\
•
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. 12,-66 (-I - S' ,
Type of benefit requested(Please he k all that apply.)
ver 65 Deduction from Aed Valuation Over 65 Circuit Breaker Credit
Name of applic ner or con ct uye
interest? If owned with joint tenant or tenant in common,indicate with whom,
U-Y-96-0 No
If name on record is different than that of applicant, ndicate below. Do all joint tenants or tenants in common reside on the property? -
E]Yes E No
Name of contract seller Has applicant owned or been buying the property under reprded contract for
at least one(1)year before claiming deduction?
es El No
Address of contract seller(number and street,city,state,and ZIP code) I t property in question:
Real property 0 Mobile home IC 6-1-1-7)
Taxing district Ke)/number/Legal description Record number Page number
Dtl°1L-15?-301- 000 SIT' -0 2-3 .
Does applicant reside on•ro,erty? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
[counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
fr1 Yes 0 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 r f a‘e 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 ar- first.ue and payable? -
LI Yes 0 No }-1-s--s-6 L.- 7•2..C 1. the spouse's age at the time of death?
Adjusted Gross Income(AGI)of applicant,applicant 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) .';s0 2-1 $ 2_6./ 0 g LI
$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 '7'0 2-2- . $ 2_ S—S 2_
Circuit Breaker Credit,AG/may not exceed:(1)$30,000 for individuals who filed a
I
single return;or(2)$40,000 for individuals who filed a joint return with the
TOTAL $individuals spouse.)See reverse for details. •
Have you filed for any other deductio . If Yes,what deductions?
es El No
.
Have you filed for deductions in any other c un y? If Ye :i.. /itirly?
r\.
Ej Yes No . --- ....-N\i'• s M \I/VVe certify under penalty of perjury that the above and foregoing information is true and correct.
V
Signatur. .fi.liTnt
‘41,944-44:
ddress.fapplicant (nu ber and street,cti,st7,v....\ code)
y clA)cl, iht,L Date(mot( y,feat
b 7A--)2---.
4tes
Signature of authorized representative • 1 Date(month,day,year)
Address of authorized representative (number and street,city,sfaterZIP-c de)
Signature of County Auditor 0/'\\JO0X,.x4.--- Date(month,day,year)
FILED
APR 0 6 2023
Y-ki,e/Lazz a.,
GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer