Age_Pierrard (2) 1 APPLICATION FOR SENIOR CITIZEN OtOUNTY TOWNSHIP YEAR
.°71/ ......'',,,I.li PROPERTY TAX BENEFITS
"' 's.-Z.-1 l. State Form 4370E(R15 t 1-20) Soo 0 0. .2 4-�n
"ads 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
Type of benefit requested(Please h k all that apply.)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of app{gnt wner r coot ail yer)
K ) )e.A.00,1(1 •0
l nD
Is applicant the sole legal r itable owner? If No,what/he'F 'cab s are or interest? If owned with joint tenant or tenant in common,indicate with whom.
es ❑No
If name on record is diffe nt an that of applicant,indicate below. J U L 31 2020 Do all joint tenants or tenants in common reside the property?
Yes ❑No
Name of contract seller Has applicant owned or been buying the property under recored co ac for
lje at least one(1)year before claiming deduction? ❑Yes No
Address of contract seller(number and street,city,state,an3lf )1p COUNTY AUDITO Is 'e property in question: •
J9�J Real property ❑Mobile home(IC 6-1-1-7)
Taxing distri
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[all 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 Dece er 1 of the year
$
Have you filed for any other de cons? If Yes,what de(du tions?
Yes ❑No 11 `J
Have you filed for deductions in any other ty? If Yes,what county?
Eyes [ No
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
1_
ignature of applicant S VAt
/� r Date(month,delyear) 2,0
Address of applicant (number and street,city,state,and ZIP c de)
`210 C )s- s-- 0DJ/ Cc-i� 1 y�- 60
Signature of authorized representative/ Date(month,day,year)
Address of auth ' ed presentative (number and street,city,state,and ZIP code)
Signature of Cou A ditor k 61/) Date(month,da,year
FILED
JUL 3 1 2020
4e4t.coratt---
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-TaxIMESON COUNTY AUDITOR