Age_Kohlmeyer •
ate,., APPLICATION FOR SENIOR CITIZEN COUNTY I TOWNSHIP I YEAR
f,i PROPERTY TAX BENEFITS
\' �,'/l State Form 43708(R14/10-17)
\ / Prescribed by the Department of Local Government Finance
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS: To be tiled in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property:During the twelve(12)months
before March 31 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Type of benefit requested(Please check all that apply.)
01 Over 65 Deduction from Assessed Valuation ❑Over 65 Circuit Breaker Credit
Name applicant(owner ey buyer) .0
Stephen Lee Kohlmeyer
Is applicant the 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.
❑Yes 0 N Brenda Lou Kohlmeyer
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common reside on the property?
2Yes 0 N
Name of contract seller Has applicant owned or been buying the property under recorded contract for
at least one(1)year before claiming deduction? ❑yes 0 N
1 Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
p teal property ❑Mobile home(IC 6-1-1-7)
Taxing district
is the applicant 65 years of age or more on December 31 of the year Applicant's date of birth(month,day,year) If filed by a surviving,unmarried spouse,what was
poor to the year taxes are first due and payable? rh Yes ❑No November 10, 1950 the spouse's age at the time of death?
Adjusted Gross Income(AG))of applicant,applicant and spouse,or applicant
(
Have you filed for any other deductions? If Yes,what deductions?
Wes ❑No
Have you filed for deductions in any other county? If Yes,what county?
❑Yes ONo
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Y Signat a plican Date(month,day,yea
— vt/ 11- Lo - 1t.
dress of applicant (number and street,city tate,and ZIP code)
590 S / ,friC�SCo ! �T‘f 9
Signs ure 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,day,year)
FILED
APR 6 2018
fiDISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer GIBSr)'N COUNTY AUDITOR