Age_Johnson (3) dj"="a APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
'd - PROPERTY TAX BENEFITS
JIb S� n �� .
S` / State Form 43708(R13/4-15) ao
'su` 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 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)
n Over 65 Deduction from Assessed Valuation (JQ Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
rtaci, 3ohnsof .
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,
Xn'
indicate with whom
Yes ElNo
It name on record is differthat of applicant,indicate below Do all joint tenants or tenants in common reside on the property?
AILED kYes ❑ No
Name of contract seller Has applicant owned or been buying th property under recorded
contract for at least one(1)year before claiming deduction?
APR 9 2019 ❑ Yes ❑ No
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
' , ' al Real properly�A —j• p p y ❑ Mobile home(IC 6-1-1-7)
Taxing district GBs,W C& =•di YdMiR,TOR ecord number Page number
Q ' Ara-1g-toe-000?-66-
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
182,430 for Over 65 Deduction or S159,999(counting just the homestead site)for the Over
❑ NO 65 Circuit Breaker Credit)
Yes See reverse for details.
Is the applicant 65 years of age or more on DeceKS
1 of the year
Adjusted gross income of applican , a licant and spouse, or Source of Income Amount of Income
applicant and joint tenants or tenants in common,as applicable(For Over 65 Deduction, income may not exceedGCNICN) IS
S25,000;for the Over 65 Circuit Breaker Credit, income may not
exceed S30,000 for individuals or S40,000 for married couples.).
TOTAL I S 0.00
Have you filed for any other deductions? �,/ If Yes.what ldeductions?
I \Yes ❑ No 14`StCSA / VI Wane
Have you filed for deductions in any other county?/ ���/// If Yes,what county?
El Yes I JtNo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
kS ignaluriz�pre ntative ham^ Address of authorized representative (number and street.city,state,and ZIP code)