Age_Slade �E��r,� APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�1 `y PROPERTY TAX BENEFITS
VIII'b== . State Form 43708(R15/1-20) S3001 . O2- 2Qr7_ 2<. Prescribed by the Department of Local Government Finance o vv 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.
�
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 h ck all that apply)
Opveryer)65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applcant(owner or con ract
U0 I' tarn G l f�- /U.eL S(acle_ .
Is applicant the sole legal ore able 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 different than that of applicant,indicate below. , Do all joint tenants or tenants in common resi e o the property?
Yes ❑No
Name of contract seller " - • Has applicant owned or been buying the property under d contract for
at least one(1)year before claiming deduction? Yes ❑No
Address of contract seller(number and street,city,state;and ZIP code) e property in question:
Real property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
• 02 F • 26--12-1c6-201 -002.4LI1 -02S .
Does applicant reside on p p rty? 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 tall 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 a e or more`on Decem er 1 of the'year
individual's spouse.)See reverse for details. .
Have you filed for any other dedu ons? If Y�eg},chat deductions?
Yles III No
l r �S
Have you filed for deductions in any other`�' u ty? If Yes,what county?
❑Yes LdNo
I/We certify under penalty of perjury
that the above and foregoing information is true and correct.
`p S g to of pylicant e i^�r) n /) Date(moot a,yea
Address,of applicant (num er and street ity,state nd code)
(02G S Cr) son -St f 11'Dtn-- JN -- y9M • -
Signature of authorized representative I Date(month,day,year)
Address of authoriz repre tative (number and street,city,state,and ZIP code)
Signature of County A ' r .__ Date(moot, ay,}ear)
. 11-/�` OI` n
'7 f 4
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• SEP 0 9 2020 C j
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Ta vArSON COUNTY U OR