Age_Houchins <4 '.4,I. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
State Form 43706(R18/9-24)
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s'i) ,. 0-r\ 60 4 zo z
nil 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
Name of Applicant(owner r contr ct uyer)
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 Tenants or Tenants in Common Reside on the Property?
Eyes 0 No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
One(1)Year before Claiming Deduction? CI Yes CI No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question:
Real Property CI Mobile Home(IC 6-1.1-7)
Taxing District Key Number I Legal Description 2-2_ki-too-000. Li-co Li
Record Number Page Number
0(0 4 26-t 2)
p
Does Applicant Reside on Property? Assessed value of the property as of current year assessment date(May not exceed$240,000 for Over 65 Deduction or
$199,999(counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,$199,999 fall
Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019 and before January 1,2023,
)(Yes 0 No and$239,999[all Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2022.)See
reverse for details.
Is the Applicant 65 ears of Age or More on December 31 of the Year Prior
Yes El No r
Have You Filed for De u ion in Any Other Co nt ? If Yes, hat County?
.I)
0 Yes No 4PR 22 ,
Sign
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
e of Applicant Date(mIticdfix,4eeafr)
Date
XAdd ess of Applicant(number and street,city,state,and ZIP code)
•41 IN
444 .-C7fr
Signature of Authorized Representative Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of County Auditor Date OR,day,rad
Pr\kACIA-1A—kn_E Q) 2
DISTRIBUTION: Original-County Auditor;File-Stamped Copy-Taxpayer