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Age_Heacock oER,� APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR �'-, >: PROPERTY TAX BENEFITS vitr; O tlity State Form 43708(R15/1-20) 1: -tt �0 Z. ��aig�r' Prescribed by the Department of Local Government Finance `'�Sv LJ !— J 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. r- . See reverse side for additional instructions and qualifications. Over Deduction from Assd sed Valuation Over 65 Circuit Breaker Credit Name of applicant(owner orcontrac uye �+c �{✓ "-Th. c QDOCA . Is applicant the sole legal o uitable owne . is is/her exactshiare or i est? • If owned with joint tenant or tenant in common,indicate with whom. Yes ❑No If name on record is diffe nt t an that of applicant,indicate below. Do all joint tenants`or tenants in common resid the property? Yes ❑No Name of contract seller Has applicant owned or been buying the property and re ed contract for at least one(1)year before claiming deduction? es ❑No Address of contract seller(number and street,city,state,and ZIP code) I t property in question: Real property ❑Mobile hom (lC 6-1-1-7) Taxing district Key number/Legal description Record number Page number 26—ly—A8-302-000 .4g8- o04- , 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 (counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real ❑Yes ❑No property]for a 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 3 the year $ individual's spouse.)See reverse for details. Have you filed for any other deducti If Yes�whatddeeductions? Yes ❑No J ,"' Have you filed for deductions in any other county? If Yes,what county? ) ❑Yes ill No I/We certify under penalty of perjury that the above and foregoing information is true and correct. rur9f1 plicant Date(month,day,year) ? t/6M r- a_./IaAI s o appli n (num er and tree(,city,state,and ZIP c de) — 3\ $ �� 17 � , o j loii�' G - � .- 1 -. ---‘ G D Signature of authorized representative ate(month,day,year) Address of authorized representative (number and street,city,state,and ZIP code) '.40..Y Signature of County Auditor Qate(moth,day, ear) ,-QL ifr g0GGJN�� � P G�0 DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer