Age_Hicks wr/ APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
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��� PROPERTY TAX BENEFITS
i' ']'``�i' State Form 43708(R15/1-20) k CO� (�„���'7/X� I'
;;' Prescribed by the Department of Local Government Finan Ort
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Information contained in this document is CONFIDENTIAL pursuant to IC 6,-..35-9.- AA"" d\1O
INSTRUCTIONS: To be filed in person or by mail with the County Auditor
of the
aoaf e sihe property is located.
Y
Filing Date: Form must be completed and signed by December 31 iC . .'.'hh the county auditor or postmarked by the following
January 5 of the calendar year in which the property taZare first due and payable. \
Type of benefit requested(Please check all that apply)
®Over 65 Deduction from Assessed Valuation ®Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer) D
�hi /� 3 � 'Is applicant the sole legal or equitable owner? Ift is his/her exact share or interest?esn 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 the property?
Yes ❑No
Name of contract seller Has applicant owned or been buying the property under recorded contrac r
at least one(1)year before claiming deduction?
III Yes No
Address of contract seller(number and street,city,state,and ZIP code) Is the p party in question:
eal property ❑Mobile home(IC 6-1-1-7)
Taxing district �� Key number/Legal description Record number Page number
n CAS Z6 -13.—/9-2.� ?- 000 •i 5-9--o 0-1---
Does applicant reside on pro a 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 ag or more on Dece r 31 of the year Applicant'
single return;or(2)$40,000 for individuals who filed a joint return with the TOTAL $
individual's spouse.)See reverse for details.
Have you filed for any other deduc' s? If Yes,Makde uctions?
Yes El No L
Have you filed for deductions in any other ou ? If Yes,what county?
❑Yes No
INVe certify under penalty of perj ry th t the above and foregoing information is true and correct. /
Signature of applicant r Date(month d y y}� „2... r
Address of applicant (number/ ndandtstreet,city,state,and ZIP code) 1� `� J
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
i
Signature of County Au 'to Date( onth,d y ar)
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer