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orf* ... APPLICATION FOR SENIOR CITIZEN JLFP1NTj1 TOWNSHIP YEAR
i % s PROPERTY TAX BENEFITS 0S3
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State Form 43708(R15/1-20) (30 r2•0
;A16 Prescribed by the Department of Local Government Finance
DEC 3 2020 0 •
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
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INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county WA) opJOis)oc^ai cl]?(TOR
Filing Date: Form must be completed and signed by
See reverse side for additional instructions and qualifications.
Type of benefit requested(Please check all that apply.)
Vi Over 65 Deduction from Assessed Valuation Egi Over 65 Circuit Breaker Credit
Name of applicantaiact buygr)
Is applicant the sole legal ore. itable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
Yes El 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?
El Yes ❑No
Name of contract seller Has applicant owned or been buying the property under recorde ntract for
at least one(1)year before claiming deduction? es ❑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)
Taxn distrigt Key number/Legal description Record number Page number
oZto -/1 - l07, • •2vq.-DD3. / -O &
Does applicant reside on prop rty? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
Yes ❑N o (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
AYes ❑No 114
Have you filed for deductions in any other county? If Yes,what county?
❑Yes �IJo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant • Date(month,day,year)
Address of applicant (number street,city,state,and ZIP code)
to M. CaKkct Stet WIKati \ -1\1 141to'l0
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Sign tur of County Auditor Date(month,day,year)
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer