Age_Hopster ..0-1-,,,-.. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
j, PROPERTY TAX BENEFITS
State Form 43708(R15/1-20) � � "
"�^;e l 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 31 and filed with the county auditor or postmarked by the following
January 5 of the calendar year in which the property taxes are
Ov 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of licant(owner or co t c uy r)
r1is pv\o
nksk� •
Is applican the sole legal r No unable If No,what is his/her exact share or in rest?• If owned with joint tenant or tenant in common,indicate with whom.
Yes No
If name on record is different t an that of applicant,indicate below. Do all joint tenants or tenants in common reside he property?o
es El No
Name of contract seller Has applicant owned or been buying the property under re d contract for
at least one(1)year before claiming deduction? es ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is l property in question:
eal property ❑Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description r Record number Page number
Q �� " 2-E — 1a-is-t01- 001. 1' `-4- —02&.
Does applicant reside on props ? 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 fall Indiana real
Yes ❑No property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for data//s.
Is the applicant 65 years a or more on Dece er of the year
$
individual's spouse.)See reverse for details.
Have you filed for any other de ucc' ns? ► If es.wh. dons? tl�
Yes ❑No C\L.,Y�:_
Have you filed for deductions jt'�anther ou ? If Yes,what county? I
❑Yes /� N
I/We certify under penalty of perjury that the above and foregoin rmation is true and correct.
X 5i atPPl'cant Date(mon y„pe � '
S
Aggpass of appii nt tqumbei and sFc@et,.ci statand de)
Signature of authorized representative Date(moil! dt1e
Address of authorized representative (number and street,city,state,and ZIP code) X.
G...
Signature of C, oyrttlCAudito Date(m nl,ilay )�^
(�(,_(�1 FILED
DEC 1 5 2021
/hec,/ Z.�C/u C C2.t4 -n.)
GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer