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APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
4. State Form 43708(R13/4-15) CO� ��%a Prescribed by the Department of Local Government Finance
before March 31 of the year the deduction is to be effective. I^
See reverse side for additional instructions and qualifications. S r 1ekke
Type of benefit requested(please check all that apply)
Over 65 Deduction from Assessed Valuation •
❑ Over 65 Circuit Breaker Credit
Name of applicant owner or nfract buyer)
v � F 3Dna.S
Is applicant the sole legal or eqw ble owner? 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 t Do all joint tenants or tenants in common reside on the property?
ILF, �) �/
�(i Yes ❑ No
Name of contract seller APR 2 3 2019 Has applicant owned or been buying the property under recorded
contract for at least one(1)year be`oorre aiming deduction?
Imo,Yes ❑ No
Address of contract seller(number and street,city,state,and ZIP code) Is the pro inquequestion:o / \
GIBSON COUNTY AUDITOR � ay\ea
MI property ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Reco number Page number
qL 23- it'-100•- 000 sic/ "csisA
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$759,999(counting just the homestead site)for the Over
❑ No 65 Circuit Breaker Credit.)
YesSee
Have you filed for any other deductions? If Yes,what deductions?
Yes ❑ NoII a
•
Have you filed for deductions in any other county? If Yes,what county?
❑ Yes ❑ No
IMe 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)
UDf 64 S 3stC , i -on- km€ 3�
Signature of thonzed representaC Address of authorized representative (number and street,city,state,and ZIP code) •