Age_Kiesel /E�4� APPLICATION FOR SENIOR CITIZEN
�� =; 1 PROPERTY TAX BENEFITS COUNTY TOWNSHIP YEAR
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StatesForm 43708the epa t 1-20) lb L n zo 2^/��/
�18�� Prescribed by the Department of Local Government Finance 4,
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.
Type of benefit requested(Please check a at apply.)
Over 65 Deduction from Assessed Valuation ❑Over 65 Circuit Breaker Credit
Name ofof applicant(owner or contract- buyer)y /�
L�LC_/ Q� /Y . Y,
Is applicant the sole legal r e uitable 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 differ nt than that of applicant,indicate below. Do all joint tenants or tenants in common reside on the property?
❑Yes ❑No
Name of contract seller Has applicant owned or been buying the property under recorded contract for
at least one(1)year before claiming deduction?
❑Yes ❑No
Address of contract seller(number and street city,state,and ZIP code) I the roperty in question:
eal property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
�� /. avze �, 2d-/9/f 302-odD - D�.-O.2_2,0
Does applicant reside on p y?
KAssessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
es ❑No (counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999(all Indiana real
property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years o or more on December 1 of the year
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Have you filed for deductions in any other county? If es,what county?
❑Yes ❑No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of plicant Date(month,day,year)
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Addre7 of applicant umber and street, '' ,sta Zl C ( [a L - �-- '- ` ' / / l O
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Signature of authorized representative y Date(month,day,year)
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Address of authorized representative (number and street,city,state,and ZIP code)
Signs re o untyAuditor . Date(month,day,year)
.4V/YVE.-i-Al-tt-C--/-411 7-/1.0- 7p.2_.
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JUL 16.2020
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer
GIBS" CO Ly�Tlr F''�