Age_Hasenour 57,,-,r,. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
. �' ' PROPERTY TAX BENEFITS _- —
' i: State Form 43708(R15/1-20) \ �� /lY) M�,
"-�• Prescribed by the Department of Local Government Finance J V� vV w •
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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 eck all that apply)
I�Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or con'a .uyer) "�" e-sek0 U41 •
Is applicant the sole legal ore unable owner? If No,what is i/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
II Yes ❑No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common reside on t property?
es ❑No
Name of contract seller Has applicant owned or been buying the property under recorde ntract for
at least one(1)year before claiming deduction? Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is property in question:
eal property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
.2— -- )b -Z\l-1 O I—Ot52- .111 b ^'OZ c---
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
[counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999 fall Indiana real
III Yes El No
property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years of age or more on Dece er 1 of the year
S' na f of applicant Date(mi ntt� r year)
Address of aOcant (number d street, rty,state,and Z code)
01
Dy1 s �fi o► = .;;y Q 4: -
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of County r ate(month,day,year)
(6-
S)1)
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer