Age_Domes , . APPLICATION FOR SENIOR-CITIZEN N COUNTY TOWNSHIP YEAR 1
4 t r w PROPERTY TAX BENEFITS
-`�..: State Form 43708(R1511-20) 1
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,,,,, Prescribed by the Department of Local Government Finance. i
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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 Delp Fonn must be completed and signed by December 31 end filed with the county auditor or postmarked by the following
January 5 of the calendar year in which the property taxes am first due and payable.
See.reverse side for additional instructions and qualifications.
Type of benefit requested(Please check all that apply.)
�IOver 65 Deduction from Assessed Valuation ®Over 6S Circuit Breaker Credit
Name of applicant(owner or contract buyOer)
I Steven L. & Cecilia A. Domes
i is applicant the sote Legal or equitable owner? If No,what is his/her exact share or interest? It owned with joint tenant or tenant in common,indicate with whom.
®Yes IDNo
if name on record is different than that of applicant,indicate below: Do all joint tenants or tenants Ur common reside on the property?
®Yes ❑No
Name of contract seller Has applicant(wined or been buying the property under recorded contract for
N/A at least one(1)year before claiming deduction? ®Yes 0 No
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
N/A . Real property ❑Mobile home(IC 6-1-1-7). t
Taxing district Key number/Legal description Record number Page number
Patoka Township 25-12-15-200-000.282-027
Does applicant reside on property? Assessed value of
the spouse age at the time of death?
IAdjusted Gross Income(AGl)of applicant,applicant and spouse,or applicant
individuals spouse.)Soo reverse for details.
Have you filed for any other deductions? If Yes,what deductions?
I, E1Yes ❑No Homestead & Mortgage
ti Have you tied for deductions in any other county? if Yes,what county?
❑Yes INo
INVe certify under penally of perjury that the above and foregoing information is titre and correct.
nalum 'a /leant` C Date(month, oy,yeer)'
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Address of applicant (number and street,city,state,and Zt coda)
3097 E. Curtice Lane, Princeton, IN 47670
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
1 Sig ire of County Auditor 1 Date(month,day,year)
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APR 3 2020
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DISTRIBUTION: Original-County Auditorr; He-Starved Copy-Taxpayer GjgSoiV CO
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