Age_Thomas (2) ..,... .,..!.. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
Y \ PROPERTY TAX BENEFITS
.: .0*
State Form 43708(R15/1-20) 1 _,Se il 0P,7 ')-o El
- Prescribed by the Department of Local Government Finance
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 3/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 che k all that apply.)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or contrac uyer)D002
-g3k IVIOnfA
Is applicant the sole legal e uitable owner? If No,what is his/her exact share or interest?
Xt
Yes 111 No If owned with joint tenant or tenant in common,indicate with whom.
If name on record is differ an that of applicant,indicate below. Do all joint tenants or tenants in common reside on the property?
Elves El No
Name of contract seller Has applicant owned or been buying the property under reçored contract for
at least one(1)year before claiming deduction? Yes El No
Address of contract seller(number and street,city,state,and ZIP code) l,th9property in question:
Real property E]Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
02.2g A-I 2_—06-303-oot 9-3C - 0 2:9
Does applicant reside on pr y?K
Yes No Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
(countingpe justforutiheecl)TemreAtecEl Circuit
Breakerfor the gmvedritIn5it=uaitpreadkrorrCainpedrif naceemivtderbrior2e0p97,Ltry lie202%ando,rII ras99.9[all Indianareal
Is the applicant 65 years o ag r more on Decem r 1 of the year
$
individual's spouse.)See reverse for details.
Have you filed for any other deduc*ons? lfiYisrh cl...1&1u,:tiqns?
Yes 0 No 41ftk .
Have you filed for deductions in a other o ty? If Yes,what county?
Elves No
I/We ce 'fy under penalty of perjury that the above and foregoing information is true and correct.
xSignatur p lica , Date(m ointt I/AT
Aglidress of aptz "(Onut 13 and street, K city;state,vd1'
\ZI,P code) 3,...0
46 i OV1/4-10AOC -- ' 0Y1.-- '- kill 6-9-0 _
)
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of County Auditor 1.,\IttsA. --.,..s,
..F(l ....."
ED Datiat rill,
NOV 2 4 20Z1
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GISSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer