Age_Richardson FI ,'-' --
0,____ APPLICATION FORSENIORIt
4 �, O CITIZEN COUN Ta rP YEAR
i'` .- a PROPERTY TAX BENEFITS,. .;
\•�� .�k;> State Form 43708(R15/1-20) �So DC 3 u .
-;a Prescribed by the Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. GIBBON COUNTY AUDITOR
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 takes are first due and payable.
See reverse side for additional instructions and qualifications.
Type of benefit requested(Please check all that apply.)
Over 65 Deduction from Assessed Valuation OrOver 65 Circuit Breaker Credit
❑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?
•It'es ❑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 pro erty in question:
Real property ❑Mobile home(IC 6-1-1-7)
Taxi istrict .
Wes 0 No /J S /yr*, .
Have you filed for deductions in any other county? If Yes,what�county?• J .
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El Yes ❑No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
)/ Signa •
ture of applicant
�� /II/ �////� 'Date(month,,day,year)
•VAddress of applicant (number and street,city,state,and ZIP code)
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/ 7 1, 24,d }0f,,;74 l A,'7k7d .
Signature of authorized representative 1 Date(month,day year)
Address of authorized representative (number and street,city,state,and ZiP code)
Signature of
County'Auditor Date(month,day,year)
4//1-1/4i /e./...(-- . .
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer