Age_Price oE. 4 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�a PROPERTY TAX BENEFITS
Kt: State Farm 43708(R15/1-20)
Prescribed by the Department of Local Government Finance
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 check all that apply.)
ICI Over 65 Deduction from Assessed Valuation ®Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
Rick Price
Is applicant the sole legal or equitable 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 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:
Real property . ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
Patoka Twnship 26-11-01-100-000.560-027
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
El Yes CI 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 of age or more on December 31 of the year
$
Have you filed for any other deductions? If Yes,what deductions?
Yes No Homestead M
Have you filed for deductions in any other county? If Yes,what county?
III Yes IINo
INVe certify under penalty of pe' that the above and foregoing information is true and correct.
Signature pli t Date(month,day,year)
y\I�/ 11/2/2020
Address of applicant (number and street,city,state,and ZIP code)
1094 N Old US Hwy 41, Princeton, IN 47670
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Sign ure of County Auditor Date(moth,day, ear)
1 �� aj� o,X).
FI -
NOV 2 2020
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer
GIBSON COUNTY AUDITOR