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d,,,, ' APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP i YEAR
41- .. 1 PROPERTY TAX BENEFITS
5140'. . State Form 43708{R19/ 7-25) L.� ���`�' 1. .r.._]
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Prescribed by the Department of Local Government Finance
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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 rs located.
Filing Date Form must be completed, signed, and filed with the county auditor or postmarked by January 15 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 (Please check all!hat apply)
(ever 65 Credit ver 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer)
with Joint Tenant or Tenant in Common. Indicate with Whom
Q Yes ❑ No
If Name on Record is Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in Commo eside on the Property?
Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Prope Under Recorded Contract
for at Least One (1)Year before Claiming redit?
Yes n No
Address of Contract Seller (number and street, city, state, and ZiP code) Is the Pr erty in Question.
Real Properly ❑ Mobile Home (IC 64.1-7)
Taxing.District Key Number / Legal Description Record Number Page Number
.tast- I-Ne . et A -0__-_D -• 15-300 (:). ::21--q._
Did Applicant qualify for the homestead standard deduction in the preceding year (or was applicant married at the time of death to
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead property in the immediately es ❑ No
preceding calendar year) and does Applicant qualify for the homestead standard deduction in the current year? --
Is the Applicant 65 Years of Age or More on December 31 of the Year Prior to the Year Taxes are First Due& Payable, des 0 No
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I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signatur o App cant , n Date (month. day. year)
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Address of Applicant (number and street. city, state, and ZIP code)
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Signature of Authorized epresentative Date (month, day, year) '
Address of Authorized Representative (number and street, city, state. and ZIP code)
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Signature of County Auditor Date (month, day. year)
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DISTRIBUTION: Original - County Auditor; File-Stamped Copy - Taxpayer
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GIBSON COUNTY AUDITOR