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Age_Woehler 7,,7•*F,� APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR 1 r PROPERTY TAX BENEFITS ladiJ St=+ Sta Prescribed by the Department of Local Government Finance op 1 V 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. Over 65 Deduction from Assessed Valuation L�1 Over 65 Circuit Breaker Credit Name of applicant(owner or con rad uyer) f 1 L-S1 i °D e. `e/ Is applicant the sole legal o�rr `'table owner? If No,what is his/her exact!share or interest?el)) If owned with joint tenant or tenant in common,indicate with whom. L,Q\Yes ❑No If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common resid o the property? Yes ❑No Name of contract seller Has applicant owned or been buying the property under rec ded 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 th property in question: Real property ❑Mobile home(IC 6-1-1-7) Taxing district t \ • Key number/Le al description Record number Page number © 2C` 1$^36'-Lk 04-d00` 4°1 -CO Does applicant reside on rty? xAssessed 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[all 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 or more on December 1 of the year $ Individual's spouse.)See reverse for details. p Have you filed for any other deductio . If Yes,what deductions? h N ^t1n, TT 10 Vet • es ❑No `t1 J v Have you riled for deductions in any other o ty? If Yes,what county? ) ['Yes No I/We certify under penalty of perjury that the above and foregoing information is true and correct. X Sig ure of applicant Date(montp,day,year) l) O L 1�1 �0 2.0 Address of applicant (number and street,city,state,and ZIP c de) _ �� `0 7 S Ipe,r1 l t ' - an Signature of authorized representative / Date(month,day,year) Address of a :�sentative (number and s t city,state,and ZIP code) I Signature of t A •'•r ,; ��1 n Date(montOh,d��e ram) Ix V Vort-Q1 _c oft • '( 1°9\ GOk.N� G\S - N DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer