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.0"'''a APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
"1 PROPERTY TAX BENEFITS
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'`. Stale Form 43708(R16/1-23) 1 —Nr3V) Oz ---- ZoLI
M6 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. )C6Type of Benefit Requested(Please the all that apply)
Over 65
Owned with Joint Tenant or Tenant in Common,Indicate with Whom
❑ 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 he roperty in Question:
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing Districtfm Key Number/Legal Description Record Number Page Number
2_6-12-o9^3oo-0oo 22_l —024 -
Does Applica)1(de 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
Yes 0 No (� •
Have You Filed for D ction in Any Other C n ? If Yes,W t County?
❑Yes No
I/We certify under penalty of perjury th t t e above and foregoing information is true and correct.
Signature of Applicant Date(month,day,year)
4 C,f nag/L- , (71&tc P074) /1-og-a q
Address of Applicant(number and street,city,state,and ZIP code)
{CS7 Est 6 C
Signature of Authorized Representative 1 i Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Sire of County itor P0 'zieDate(m nth, a r)
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DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer °,b =.
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