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Age_Johnson �Fm"*, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR —`-''\4 PROPERTY TAX BENEFITS at`�a�'► �\-`I i`,;. �) State Form 43708(R15/1-20) [[�� ©0 1' n ^rt ^ \ja 6'-`. Prescribed by the Department of Local Government Finance J '�� !�(J l�.J 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 6 c ion rom sse luation L Over 65 Circuit Breaker Credit Name of applicant(owner or contract buye ��a .� 1 I // \\ //, r 1 � Jo�trlsoh k -S`) / kfNoi�dh"RSov) 1. CIC�� too nail K, Is applicant the sole legal r e uitable owner? I o,w r exact share or interest? If owned with joint tenant or tenant in common,indicatg with whom. Ui Yes ❑No ^ If name on record is differe t than that of applicant,indicate below. Do all joint tenants or tenants in common reside on the property? !`�'�r XYes ❑No Name of contract seller Has applicant owned or been buying the property under re`cu>ed contract for at least one(1)year before claiming deduction? yes ❑No Address of contract seller(number and street,city,state,and ZIP code) Isproperty in question: eal property LI Mobile home(IC 6-1-1-7) Taxing district Keynumber/Legal description Record number Page number OCR - • 26 '13 -13-At 011-0 0 n g"81 "001- Does applicant reside on proocerty? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999 ICI 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 individual's spouse.)See reverse for details. Have you filed for any other de u-tions? If Yes,wha13 coons? Yes III No 11 1 GI. • Have you filed for deductions in any other co ty? If Yes,what county? III Yes No INVe certify under penalty of perjury that the above and foregoing information is true and correct. Sign 're of applicant Date(moth,day,(ear) X 4 d� i--- 1 (7i4�ZO?..7 Address of applicantmb)Z2—A-,Q._e9--v-' d street,city,state,and ZIP code) - .0‘ (A) n� s\ Oa 0 G 5n-9-66 0 Signature of authorized representative Date(month,day,year) Address of authorized representative (number and street,city,state,and ZIP code) Signature ii,101 tyAud io �-�,() 1 Date(month,day,year) j�(Y11 < Ji J 0 2-0 r2•0 . F I 1 E 1 ':- OCT 2 0 2020 C. DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer GIBSON COUNTY AUDITOR