Age_Mason (6) •
�.0,--- APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
%' %4 PROPERTY TAX BENEFITS
,:;z: i' �� Q l .2010
rl � t� State Form 43708(R15/1-20)
;a18;' 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 Date: Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the following
January 5 of the calendar year in which the property taxes are first due and payable.
See reverse side for additional instructions and qualifications. ?
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer) ,.,
3 OhT\ i . On
•
Is applicant the sole legal or equitable owne . at is his/her ex ha or teres If owned with joint tenant or tenant in common,indicate with whom.
❑Yes El No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common resid o the property?
J111 9 2020 Yes ill No
Name of contract seller Has applicant owned or been buying the property under co ded contract for
=t least a(1)year before claiming deduction? III Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) t property in question:
GIBBON COUNTY AUDITOR Real property III Mobile home(IC 6-1-1-7)
Taxi rjist' t Key number/Legal description Record number Page number
I IN 26-12-01-2oL1-0 01 .22-r=�28
Does applicant reside on property? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
['Yes ❑No (counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999 fall Indiana real
property]for the Over 65 Circuit Breaker Credit initially applied for after December31,2019.)See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
$
individual's spouse.)See reverse for details.
Have you filed for any other deductions? If Ye what deductions? ( 1A±
Yes ❑No S (�Have you filed for deductions iin any other °uty? If Yes,what county?
['Yes No •
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
`• Signature of applicant Date(mont(�i jr,y air)
Address of applicant (nu r and street,city,state,and ZIP code)
72A Fs S'r , P 1 ,., ^ D-n-- ut4-6
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Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature:�ty A C--- Date(mory year)
2.
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer