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"A,. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
" �` "' ° PROPERTY TAX BENEFITS
\.1410fr State Forth 43708(R 19! 7-25) To, aL2
... 'M• Prescnbed 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 bled with the county auditor or postmarked by January 15 of the calendar year in
winch 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)
QOver 65 Credit Over 65 Circuit Breaker Credit
Name of Applicant (owner or contrail r) Telephone Number Email Address
L \t‘.. .ci cl- .t_be_ c_ �ai..r IC`c ( IDID ) '
- cclq ____ _ _
Is Appligant the Sole Legal or Equitable Owner) If No, What is Applicant's Exact Share or Interes? If owned with Joint Tenant or Tenant in Common. Indicate with Whom
[YeS Q No _
If Name on Record is Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
0Yes 0No
Name of Contrail Seller Has Applicant Owned or Bought the Property tinder recorded Contract
for at Least One(1)Year before C*aimng Creel¢?'
t ---3 cI �` ( Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code) Is the Propefly in Question.
0 Real Property 0 Mobde Home(IC 6-1.1-7)
Taxing Distnct Key Number I Legal Descnpbon Record Number Page Number
\c4 ci e ear _ 3Q1, -- -) - 1 t - 1 CSC -- ao 3 ,' '--t—i- C') I .
Did Applicany for the horn J tandard deduction in the preceding year (or was applicant mamed 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 Dyes 0 No
preceding calendar year)and does Applicant qualify for the homestead standard deduction in the current year?
r
Is the Applicant 65 Years of Age or More on December 31 of the Year Prior to the Year Taxes are First Due& Payable? {. ' es El No
Applicant's Date of Birth(month, day, year) If Filed by a Surviving,Unmarried Spouse,What Was the Spouse's Age at the Time of Death?
'\-- - 1c) )aq / LDO e° QN - 1 ) 1--1 ,
`} 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, AGI '
may not exceed (I) S60,000 for individuals who filed a single return, (2)$70,000 foe QO ter_ $ `�
ndrvictuals who filed a pint return, or(3) 570,000 for ndrvrduals and a/others that
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share ownership as font tenants or tenants in common For the Over 65 Cmnt
Breaker Credit,AGI may not exceed (1) $60,000 for rrxtivwivals who bled a single B
$ 1 0 r r
return, or(2)S70,000 for individuals who hie a pint velum with the individuals
spouse.)(Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted(See reverse for details_ TOTAL $
I/We certify under penalty of perjury that the above and foregoing information is true and correct
Signature of nt Date month, day, year)
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Address of Applicant (number and street, aty, state, and ZIP code)
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Signature of At ed Representative Dale (month, day, year)
Address of Authorized Representative (number and street, city, state, and ZP code)
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Signature of County Auditor Date (month, day, year)
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2 4 2026
DISTRIBUTION: Onginal - County Auditor, File-Stamped Copy - Taxpayer / 11-ufyaL Q. tJ 4;724) ( ( Ai \
GIBSON COUNTY AUDITOR