Age_Doyle (ttizil
APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
. ) State Form 43706(R16/1-23) G 45- t\ 1.022 .
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 rriail with the county auditor of the county where the property is located.
Filing Date. Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the following
January 5 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) ,.ems
L�'TOver 65 Deduction from Assessed Valuation ' ier 65 Circuit Breaker Credit
Name of Applicant(owner or contract buyer)
If Owned with Joint Tenant or Tenant in Common.Indicate with Whom
2 Yes ❑ No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
N/A 2 Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
N/A One(1)Year before Claiming Deduction? 2 Yes ❑ No
Address of Contract Seller(number and street,city,state,and ZiP code) Is the Property In Question
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number `Page Number
Patoka Township 26-12-05-400-700.509-027
Does Applicant Reside on Property? A d value of the property as of currant year essaasmant date(May not exceed$240,000 for Over 65 Deduction or
5199,999(Counting lust the homestead site]for the Over 65 Circuit Breaker Credit received before January 1. 2020 and St 99,999(al
Q Yes ❑ No Indiana real property]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
Yes ❑No Homestead
Have You Filed for Deduction in Any Other County? If Yes,What County?
IY❑yes No
I/We certify under penalty of perjury that the above and foregoing information Is true and correct.
Signature of Applicant Date(month day year)
`YV lc -tr�-e/ 'p �-�_5-13
Address of Applicant(number and street,city,state,a ZIP code)
1409 E Conservation Dr, Princeton, IN 47670
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(month,dey,year) �I
FILED
DISTRIBUTION: Original-County Auditor; File-Stamped Copy—Taxpayer OCT 0 4 202 .,P
], ,4% a L
GIBSON COUNTY AUDITOR