Age_Quinlin •.
,>,. APPLICATIO NI EN COUNTY TOWNSHIP YEAR
°` PROPERTY TFi A E FI j /�` �/')
. State Form 43708(R1 /1-20) vt QA 0�� .�'4✓24
'`� -'�'' Prescribed by the Department of j_pct svairt Finance tl UUU
NOV J `{J�1 File Mark
Information contained in this docu e t is CONFIDVATIALpursuant to IC 6-1.1-35-9.
INSTRUCTIONS: To be filed in 1$0443Q 46 ittP8g9F4Auditor 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 ch k all that apply.) ` (� (� _`
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or con uyer) CI` Cols eye G nl;c). Res � c moans ..
Is applicant the sole legal unable owner? If No,What is his/her exact share or interest? 1 If owned with joint to t or tenant in common,indicate with whom.
Yes ❑No
If name on record is diffean that of applicant,indicate below. Do all joint tenants or tenants in common resid the property?
nt Yes ❑No
Name of contract seller Has applicant owned or been buying the property under ed contract for
at least one(1)year before claiming deduction? Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) Isroperty in question:
eal property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
02S 26-12—I1—vat-00o. 6O1--No 2-8' •
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
❑Yes ❑No (counting just the homestead srte)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 Decem r 31 of the year
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 dedu ons? If Yes,ylha�deductipns? __ `` -��/t
Yes 0 No ``J�"'C0 , �sU�.M)\�� t J •
Have you filed for deductions any other ��`` ty? If Yes,what county?
❑Yes I�Q No
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
nature of applicant Date
(month,
`'^jdayyear)
�"'L z>1.A
A ress of applicant (number and street,c state,and ZIP code) O t
Ci11 S JT\`_tI n_1 Ste, riofn-- 9n-t o 9
Signature of authorized representative Date(month,day,year)
Address of authorized representatie (number and street,city,state,and ZIP code) 1 ,�r'�
Signature o oun ditor cz Date(nto\tf►.$a e ;-/ lA, •
161 11`11t{„
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer