Age_Gengelbach .,0 mar, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�` ' `.- PROPERTY TAX BENEFITS
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n .`. 1 State Form 43708(R15/1-20)
\ r . Prescribed by the Department of Local Government Finance bJohJ 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 chec 11 that apply.)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
NameeAofipplicant(owner or contra�.uyer) it it i
�V �Yl % /) / rife 1 _ I��,,jAit Aae-12-
es ❑No
If name on record is d ffere t than that of applicant,indicate below. Do all joint tenants or tenants in common re de o 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) s th property in question: '
eal property ['Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
V�Q-672� ZLo°1 S"31Q-3oo 2 - 775 cR
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
❑Yes • ❑No (counting just the homestead site)(or the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999(all Indiana real
property]for the Over 65 Circuit Breaker CreditinitiallyappIied(or afterDecember 31,2019.)See reverse for details.
Is the applicant 65 years of age or more bn Decem a 31 of the year
$
Have you filed for any other deductio ? If Yes,what d ctions? 1 J �/f /�
es ❑No d6 5i.e.a_ /i11ot5 c ��
Have you filed for deductions in any other ou. ? If Yes,what county? J
. ill Yes ►I No
I/We certify under pehalty of perjury that the above and foregoing information is true and correct.•
XSignature of appli t i . Date(month day,year)
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Address of applicant (num er and eet,ci ,state,and ZIP code) (j
/31 5 1�t� / - a, 4 si-aO( . • v 4-/71,039
Signature of authorized,representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signatu of ounty Auditor . Date(month,day,year)
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77".DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer O''CO, UNTY MUp V►R
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