Age_Schafer t.4 APPLICATION FOR SENIOR CITIZEN
�"'`��a COUNTY TOWNSHIP YEAR
071 PROPERTY TAX BENEFITS
.. ) State Form 43708(R15/1-20) \\Q
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.1 Prescribed by the Department of Local Government Finance ��bson n; e Ql�
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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.
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Type of benefit requested(Please check all that apply.)
•
er 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Name
equit a oviner? If No,what is his/her exact share or interest? If owned with)Dint tenant or tenant in common,indicate with whom.
IFY-es ❑No
If name on record is different than that of applicant,indicate below. I Do all joint tenants or tenants in common reside on the property?
[4'"�es ❑No
Name of contract seller Has applicant owned or been buying the property under recorded contract for
at least one(1)year before claiming deduction? eS ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is the 13.toperty in question:
eat property LI Mobile home(/C 6-1-1-7)
Taxing district (� Key number/Legal description Record number Page number
UJ\n.«fit CZ.4ec acQ- OS-4/C- ((g-G 755-0( '
Does applicant reside on properly.? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
i�Yes ❑No (counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,and 5199,999[all Indiana real
I 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? Res ❑No L: a «' $1(016.2 the spouse's age at the lime of death?
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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,
S40,000 for individuals who filed a joint return;or(3)$40,000 for individuals and all $ r� yaa
others that share ownership as joint tenants or tenants in common.For the Over 65 ra a $
Circuit Breaker Credit,AGI may not exceed:(1)S30,000 for individuals who filed a �f�t(5
single return;or(2)$40,000 for individuals who filed a joint return with the
individual's spouse.)See reverse for details. TOTAL $ 0 /1 R G ;'
Have you filed for any other deductions? If Yes.what deductions?
Efes ❑No Kvtvk.eS1-eta
Have you filed for deductions in any other coountt " If Yes,what county?
❑Yes A1Vo
I/We certify under penalty of perjury that the above and foregoing information is true and correct. .
;f-Gd'tt. 11 ( jEta_e(month day,) '
Addres.of applicant (number and reet,city,state,and ZIP code)
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It-g -ture of authorized rep esentativel 1 Date(month,day,year)
Address of authorized repres/tative (nuall er and sire,, ity,state,and ZIP code) •/
Signature of County Auditor 1 G" Date(month,day,year)
MAY 17 2023
h....44,,C a nal
GIBSON COUNTY AUDITOR