Age_Glaser (1tez; APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
II
PROPERTY TAX BENEFITST. \\ 3 �O\Q
State Form 43708(R13/4-15) j l-1
a. 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 filed 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 61.1-7 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)
❑ Over 65 Deduction from Assessed Valuation I Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer) ( `
��� �Is applicant e legal equita&e If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,
AYes
indicate with whom
❑ No
If name on record is differn that of applicant,indicate below Do all joint tenants or tenants in common reside on the property?
❑ Yes ❑ No
Name of contract seller Hasa applicant owned or been bu
ying vyieg 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 property in question:
I A� Real property ❑ Mobile home(IC 6-1-1-7)
•Taxing district ( Key number/Legal description Record number Page number
‘34C0 —000 3bs—bu,
Does applicant reside on property? Assessed value of the properly as of current year assessment date(may not exceed
l� NO
$182,430 for Over 65 Deduction or$159,999(countingjust the homestead site]for the Over
65 Circuit Breaker Credit.)
Yes See reverse for details.
Is the applicant 65 years of age or more on Dece ber LJ
1 of the year
Income Amount of Incomeapplicant and joint tenants or tenants in common, as
applicable(For Over 65 Deduction, income may not exceed $
S25,000;for the Over 65 Circuit Breaker Credit, income may not MAN 1 5 2019
exceed S30,000 for individuals or S40,000 for married couples.). $
See reverse for details. • TOTAL $ 0.00
Have you filed for any other deductions? GIBBON U ions?
ITOR
Yes ❑ No S ci •
Have you Sled for deductions in any other county. If Yes,what county?
❑ Yes �No
I/We certify under penalty of perjury that the above an foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
a A 2, 4 t 364 e oo S) hs)-tA-A " 5'n
st6nature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)