Age_Krieg as"" a APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
4 PROPERTY TAX BENEFITS -_^ e-�� �7
S• r State Form 43708(R13/4-15) 1�V (tack /r 11cf•'u: Prescribed by the Department of Local Government Finance C.11` 1 •
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. C,
•1.-,� % 4-I6-kq ,
INSTRUCTIONS:To be riled 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)
❑ Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of a i nt(owner or contract buyer) �I t� � �.i�
a LAvYi `c' n a
I licant th . . If No,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?
ILE I 1 _
❑ Yes ❑ No
Name of contract seller Hasa applicant owned or been bu
ying tying the property under recorded
6 2019 contact for at least one(1)year before claiming deduction?
APR 1 J ❑ Yes -- ❑ No
Address of contract seller(number and street,city state,and ZIP code) Is the property in question:
N COUNTY AUDITOR Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district 1A r/Legal description ��' Record number Page number
2b-13-2\-10o -001 . 8 -° kn .
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
5182,430 for Over 65 Deduction or 5159,999(counting just the homestead site)for the Over
❑ No 65 Circuit Breaker Credit)
YesSee reverse for details.
Is the applicant 65 years of age or more on December 31 of the year Applicant'
Adjusted gross income of applicant, app icant and spouse, or Source of Income
No it 3kd _' [.Have you fled for deductions in any other county If Yes.what county?
❑ Yes IA No
I/We certify under penalty of perjury that the above*No
foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code) '
Sign of auth�presentativeauth�presentative Address of authorized representative (number and street,city,state,and ZIP Godly 1