Age_Dewig 444 gm APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
Y %' . PROPERTY TAX BENEFITS i aQ�a
"�:. Wit'` State Form 43708(R15/1-20) (b 5p"'1 OaU b 5
.^a .-' 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 first due and payable.
See reverse side for additional instructions and qualifications.
Type of benefit requested(Please
check all that apply.)
U vver 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or cont t b yer)
730V7A(d ` 3-0yce /9 Dew19
Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
&Petit ❑No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common reside on the-- property?
al ins IJ No
Name of contract seller /� Has applicant owned or been buying the property under recorded contract for
// t ��-,()ICIS I��` t least one(1)year before claiming deduction? 5 ❑No
J'-f' P th 7'-`h i rc.( J n d ZIP Is the roe in question:
Address of contract seller(number and street,city,state,and ZIP code) P RY
eal property 0 Mobile home(IC 6-1-1-7)
Taxing distr ct Key number/Legal description Record number Page number
Hat/bsfad/f '.�?4n-/1-31-30V-006-06,3 -OO apn6 $'a-7 fip
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$199,999
Lyf Te$ ❑No Bunting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999 fall 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 of the year
Have you filed for any other deductions? If Yes,what deductions? M
[ es El No )401)1e571-alNel �."0/ 60L e'.
Have you filed for deductions in any other county? If Yes,what county? •1 ,
El Yes ❑No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Sign lure of applicant d a Date(month,day,year)
Address of applicant (number d street,city,statee,andcode) /_ s L / _Z.-. /LJ 14 '?'6,3 9
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, Date(month,day,year)
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JAN 2 6 2022,.. -
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GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer