Age_Dearing 1"° ',"_'°4. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR�� PROPERTY TAX BENEFITS
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• tI f StatesForm 43708theep3/4-15) ( t•, 4r10,j 1b�'w"I �2
�' ie�e `` Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark 1 I
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INSTRUCTIONS:To be filed In person or by mall with the CountyAuditor 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)
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❑ Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
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Is applicant the sole legal or equitable owner? ( If No,what is his/her exact share or interest? If oicatewne w with
whn tenant or tenant in common,
yYes ❑ 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?
Vj
: Yes ❑ No Has applicant owned or been•uying the property under recorded
Name of contract seller contract for at least one(1)year before claiming deduction?
<<Qp� 2���'�� ❑ Yes ❑ No
•
Address of contract seller(number and street,4c1,te,acid ZIP code) Is the property in question:
• O� Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district nn n(b r I description Record number Page number
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26",�3 06-240,dDa- 79,1-609
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$159,999(counting Just the homestead site]for the Over
Yes ❑ No 65 Circuit Breaker Credit.)
See reverse for dotalls.
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 ,
prior to the year taxes are first due and payable? was the spouse's age at the time of death?
Yes ❑ No
Adjusted gross income of applicant,applicant and spouse,or
/ (/
Have you filed for deductions in any other county? If Yes,what county?
❑ Yes No
IlWe certify under penalty of perjury that the above and foregoing information is true and correct.
' nature of appli nt Address of applicant (number and street,city'state,and ZIP code)
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Signature authorized representative Address of authorized representative (numb and street,city,state,and ZIP code)
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