Age_Dierlam .0 APPLICATION FOR SENIOR CITIZEN
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PROPERTY TAX BENEFITS
\ '1 ` jl' State Form 43708(R15/1-20) '�•�
eT-. Prescribed by the Department of Local Government Finance
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File . •
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/@p4.ON COUNTY
AUDITOR
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
XOver 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Nam of applicant(owner ornntractbu r)
Is ap lirant the sole legal or equitable o ner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
❑Yes III No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common reside on the property?
❑Yes El 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) Is the property in question:
X Real property ❑Mobile home(IC 6-1-1-7)
Taxing tC177t-
t Key number/Legal description Record number Page number
A6 - ao , vim-iao -000. 183 -00/
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 applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
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individual's spouse.)See reverse for details.
Have you filed for any other deductions? If Yes hat deductions?
gYes El No 1 s pA 4 n
Have you filed for deductions in any other county? If Yes,what colunty? J']
❑Yes *Jo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
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XSignat of applicant, ja..s( :/ ," ' Date(month,day,year)
Addr ss of applicant (number and stree,city,state,and ZIP code)
XGAG y� Soo s' , A(701
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature q County Auditor • / Date(month,day,year)
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer