Age_Fischer ee APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
'' �1 PROPERTY TAX BENEFITS
it ' State Form 43708(R15/1-20) c(
b- �� Prescribed by the Department of Local Government Finance .]0y 1 OD
I
File Mark
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 ®Over 65 Circuit Breaker Credit
Name of applicant(owner
Is applicant the sole legal o,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
®Yes ❑No
If name on record is different than that of applicant.indicate below. Do all joint tenants or tenants in common reside on the property?
®Yes El No
Name of contract seller Has applicant owned or been buying the property under recorded contract for
N/A at least one(1)year before claiming deduction? ®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
Haubstadt 26-18-36-403-000.115-009
Does applicant reside on property? Assessed value of the property as of current year assessment date(May not exceed$200,000 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(all Indiana real
®Yes CI No
property)for the Over
$
individual's spouse.)See reverse for details.
Have you filed for any other deductions? If Yes,what deductions?
0Yes ❑No Homestead
Have you filed for deductions in any other county? If Yes,what county?
Elves [No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Sig re of applicant
7 _ Date(month,day,year)
ofc,�¢ `�, 2 )G �,a P L'
Ad pplicant (number and street,city,state,and ZIP code)
901 W Elm St., Haubstadt, IN 47639
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
' Signature of County Auditor ^'N Date(month day,year)
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FILED
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APR 01 2024
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer t (i. 42f GIBSON COUNTY AUDITOR
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