Age_Bushnell (2) -<� aE",., APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR ,!
!:ice .- PROPERTY TAX BENEFITS —•
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State Form 43708(R16/1-23)
-4.t% Prescribed by the Department of Local Government Finance
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 flied with the county audi postmarked by the following
January 5 of the calendar year in which the property taxes are first due and payab .
See reverse side for additional instructions and qualifications.
i Type of Benefit Requested(Please check all that apply)
1
Z Over 65
Owned with Joint Tenant or Tenant in Common. to Whom
Yes No
i If Name on Record is D:fferent than Applic t, dicate BB .[' Do All Joint Tenants or Tenants in Common Reside on the Property?
' \ ZYes 7 No
F Name of Contract Selle `.\ �� ' ` Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
\`
One(1)Year before Claiming Deduction? _-;•'fes _' No
I
Address of Contract Seller(number a scree y.state.and ZIP code) Is the Property in Question
'!'Real Property Mobile Home(IC 6-1.1-7)
i Taxing District Key Number;Legal Description Record Number Page Number
-rr%vICe,{-ov) 2G-la-07-9o3_ 0o3. P66- Oag
Does Applicant Reside on Property? Assessed value of the property as of current year assessment date(May not exceed S240,000 for Over 65 Deduction or
_ S199.999[counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1.2026,and S199.999[al
Yes - No Indiana real properly]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the Applicant 65 Year of Age or More on December 31 of the Year Prior
Spouse's Age at the Time of Death?
Adjusted Gross Income(AGI)of applicant,applicant and spouse,or applicant
D
exceed:(1)$30,000 for individuals who filed a single return;or(2)S40,000 for individuals who
filed a joint return with the individual's spouse.)See reverse for details. TOTAL S
I
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Have You Filed for Any Other Deductions? If Yes,What Deductions? M4 2 0 ITN—
`, 1
I ❑ j�
V s No ytveq JL ,
Have You Filed for Deduction in Any Other County? If Yes.What County? l��[i.G�iaL a.4a�ivltd/
❑Yes 12M7 GIBSON COUNTY AUDITOR
IANe certify under penalty of perjury that the above and foregoing inf rmation is true and correct.
' Date(month. day.year)
eli. Ail ,II/ . LAA i t
Address TApplicant(number and street.city state.and ZIP code)
—1 I Ct S (lace`5 ?rc.Ace, .x.1 4'76 ?O
Signature of Authorized Representative I Date(month, day.year)
1
Address of Authorized Representative(number and street.city,state.and ZIP code)
v)
\\5)
Signature of Cou tny Auditor / A! Date(month. day.yeari
DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer \� O �/\