Age_Matthew 1 • n r
.ME APPLICATION FOR SENIOR CITIZEN RECEWED COUNTY TOWNSHIP YEAR
6( r,< PROPERTY TAX BENEFITS
" T ' t,i' State Form 43708(R15/1-20) SEP 1 2 2019 G Co_/1 r)O2
r'e 6% Prescribed by the Department of Local Government Finance L J
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 h k all that apply)
l�Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or cont act b yer) �� � �G�
I�►I1YG
Is applicant the sole legal r 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 diffe nt th n that of applicant,indicate below. Do all joint tenants or tenants in common resid o he property?
Yes ❑No
Name of contract seller Has applicant owned or been buying the property under re d contract for
at least one(1)year before claiming deduction? es ❑No
Address of contract seller(number and street,city,state,and ZIP code) I t e property in question:
Real property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
261B 36-402 - 000,260 -0c9 •
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[all Indiana real
❑Yes ❑No
property]for the Over 65 Circuit Breaker Credit initially_appliedfor_after December 31,2019.)See reverse for details.
Is the applicant 65 years of age or more on Decem r 3 of the year
individual's spouse.)See reverse for details.
Have you filed for any other dedu ons? If Ygg what deductti1ions?�
Yes ❑No 111-SC i"I�v� V v e _
Have you filed for deductions in any other ty? If Yes,what county?
IDYes o
_ I/We certify under penalty of perjury that the above and foregoing information is true and correct.
y...r
eSignatuce of a plicant ( L�,r�/G�����/�N/ L Date(month,day,year)
p; . ( V� 4 0 9-D-020
Address of applicant (number and street,city,state, 'ZIP code)
303 c5 (iiu & S'� - SYl— 1ii-Oct . .
Signature of authorized representative / Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of County Aud1:1) Date , iv -r) - ai 1 i A
killVnt EL)t C vl j t s .1. : —‘ ) %
wr
12020
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IZOR
GIBSON �OVNTY HUD
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer