Age_Cutsinger Ko rr.k71 , APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
Al PROPERTY TAX BENEFITS /��
i yx# �� State Form 43708(R15/1-20) �%�/
Bar' Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
-ikl
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located.
rVnn a
Filing Date: Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the followrTiJ Q 9January 5 of the calendar year in which the property taxes are first due and payable. (020
See reverse side for additional instructions and qualifications. GfeSON
Type of benefit requested(Please check all that apply.) (J
Over 65 Deduction from Assessed Valuation J Over 65 Circuit Breaker Credit "(AOR
Namepf��pplica t(owngrorcontracfbuyer) ��%[ ✓ I /\
Is applicant the sole leg equitable owner? If No,what is his/her exacts e 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 ❑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 th roperty in question:
w Real property ❑Mobile home(IC 6-1-1-7)
Taxing Zmbce;Legal descriiptti�n Record number Page number
A -0?- 7v�?-Goo•674 - D,?2
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
es ❑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
individual's spouse.)See reverse for details.
Have you filed for any other dedu ons? If Yes, deductions'?Chat
;Yes ❑Nook
Have you filed for deductions in any other co ty? If Yes,what county? (/
❑Yes to
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signat re of applicant r Date(month,day,year)
-43- t�./o- eo ��
� Ad ss of app i n umber a d street,city,state(PIP d ZIP code)
` 1 . ►/� zw- Li.vtbizzi...„4„az • �17�70
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature tyAuditor '' ) Da//iny,yeao
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer