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- -_ ��� APPLICATION FOR SENIOR CITIZEN cot�NTY TOWNSHIP YEAR
1- t� PROPERTY TAX BENEFITS I
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�. 1 /:r State Form 43708(R16/1-23)
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-..,!ete..% 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 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)
❑✓ Over 65 Deduction from Assessed Valuation O Over 65 Circuit Breaker Credit
Name of Applicant(owner or contract buyer)
lillywilly@gmail.com
Is Applicant thee Sole Legal or Equitable Owner? If No,What is His/Her Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
t[v Yes ❑ No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
❑ Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
One(1)Year before Claiming Deduction? ❑✓ Yes ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Properly in Question:
El Real Property ❑ Mobile Home(/C 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
025 26-19-09-100-001.096-025
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,and$199.999(al
❑✓ 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
$
Have You Filed for Any Other Deductions? If Yes,What Deductions?
0 Yes ❑No Homestead
Have You Filed for Deduction in Any Other County? If Yes,What County?
❑Yes ❑r No
I]We certify under penalty of perjury that the aboveregoing inform 'on is true and correct,
gnatr a of pplicant Date(month,day,ye r) / ,
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Address of'pplicant(number and street,city,state,and ZIP code)
5696 S 175 E, Ft 'ich - IN 47648 /1 �y�e fn
Sig at re f Au orize epre nlal've ,OA Date(month,day,yea)
Address (/Authrized Ste ese�layve(rr�rmb/ef nd street,city, t !e,and ZIP cod ) di ( � 3
Sign to of�u(n(�t//y)AL/uditor t1jS (/7/(ai()I/y 5U,..5(rititie...' " Date(mon ,day, ear)
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NOV 07 2024 % •
DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer J L
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GIBSON COUNTY AUDITOR
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