Age_Wilson (2) �E re,• APPLICATION FOR SENIOR CITIZEN COUNTY T NSHIP YEAR
' .k PROPERTY TAX BENEFITS
a' : ': $i' 26.
t",, 0, State Form 43708(R15/1-20) ,
Prescribed by the Department of Local Government Financeh,„ ,,,,
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.)
❑Over 65 Deduction from Assessed Valuation LI Over 65 Circuit Breaker Credit
Idameb )f�applicant(owner or contract buy Ufr / 6
Is applicant the sole legal or equrt -owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
P. es ❑No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common reside on th perty?
IllPfes ❑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 F .Nt>—
Address of contract seller(number and street,city,state,and ZIP code) Is the pro in question:
eal property ❑Mobile home(IC 6-1-1-7)
Taxi di n Key number/Legal description Record number Page number
1`hGQ_kfi'�• sz,4 6,4,-/z-A03 - 001- /c-G-4D 2 e
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
❑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 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 o e year
$
individual's spouse.)See reverse for details.
Have you filed for any other deductions'? If Yes,what� deedducctiioons? / ,, �/ /�J 1
es ❑No ii //!"1dcL5/EyLLGL, //�/�2TC rHave you filed for deductions in any other county?? ems,what county? o❑Yes o
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature f applicant �, ),. /j Date(month,day,year)
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ddr ess of icant (number anJd street,ci te,and ZIP code) �i
1
D AI .� �7t 77D
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signat f County Auditor • Date(mon h,day,y ar)
Leiy-Lu922 0- t(Jaiktk) le-
t ,O__
FILED/ . .
FEB 17 2021
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer % 1l1GC c.G..14.
GIBSON COUNTY AUDITOR 7