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"'4ltN. APPLICATION FOR SENIOR C N COUNTY TOWNSHIP YEAR
•;.siiii;„ PROPERTY TAX BENEFITS }
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State Form d371)8(R19/ 7-25) �} `
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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, 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 that apply)
pOver 65 Credit Over 65 Circuit Breaker Credit
Name of Applica t (ower uyer) Telephone Number Email Address
8
is Applcant the Sole Legal or Equitable Owner? If No. What is Applicants Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common. Indicate with Whom
\', 0 yes 0 No
If Name on Record is Different than Applicant. Indicate Below Do All Joint 1(rants or Tenants in Common Reside on the Property?
._J Yes 0 No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One(1)Year before Claiming
Yes ❑No
Address of Contract Seller (number and street, city, state, and ZiP code) Is the Property in Question:
pf.Real Property ❑ Mobde Home(/C 6-1. 1-7)
Taxing District Key Number/Legal Description 'Record Number Page Number
0. 4, -/ 7 -// - /oU - 000. a ` 3 - v /
Did Applicant q ify for the estead standard deduction in the preceding year (or was applicant marred at the time of death to
a deceased spouse who quail fed for a homestead standard deduction for the individual's homestead property in the immediately El Yes El 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? Yes El No
App cam's Date o i nth, day, year) .Z _ i 9 _ 3 7 It Fled by a Surviving,Unmarried Spouse,What Was the Spouse's Time
e's Age at the me of Death?
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Source of Income Amount of Income
Adjusted Gross Income (AGI)of applicant, applicant and spouse,or applicant
and joint tenants or tenants in common,as applicable (For Over 65 Credit, AG!
4-tP;)P C•<2—-1"-;6.,64
may not exceed. (1)$60,000 for mdnnduals who fled a single return; (2) 570,000 for i% C 4 — S
individuals who filed a joint return;or(3)$70,000 for rndnndrlals and at others that
share ownership as joint tenants or tenants in common. For the Over 65 Cvaaf
Breaker Credit. AG!may not exceed (1) $60,000 for individuals who Ned a single a f] GL 5 "62,9.6..,,,e,l,..Z.e______,
return, or(2)$70.000 for individuals who filed a joint return with the inclivtdua/'s -
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spouse.)[Beginrxng with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted)Sec reverse lbr details. TOTAL S
INVe certify under penalty of perjury that the above and foregoing information is true and correct
• Signature of Applicant q� / ` Date (month, day. year)
s 1C-412, 14-6d yt- .
Address of Applicant (num r and str , city, state. and ZIP code) --
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Srgnaii$e of Authorized Represents ve Date (month.
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Address of Authortztitl Re nt ' number and street, ty, state, nd ZIP codie)
Signature of County Auditor -- Date (month, day, )f )g 1 1 2026
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GIBSON COUNTY AUDITOR
DISTRIBUTION: Onginal - County Auditor. File-Stamped Copy - Taxpayer