Age_Montgomery ,i+ *a APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
y 1 PROPERTY TAX BENEFITS i b5a� �� ^C*l �a
! .,, State Form 43708(R15/1-20)
,---�•�" Prescribed by the Department of Local Government Finance
•
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,,cch-h,ec�k-all that apply)
i5 er 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Name of applicant(owner or contract buy,keiA
J o �e. /vcon finer-1
Is applicant the sole legal equitable owner? f No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
❑Yves ❑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?
❑Yes ❑No
Name of contract seller Has applicant owned or been buying the property under recorded contract for
at least one(1)year before claiming deduction? El Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is the Ergperty in question:
eal property ❑Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
a4-1g-13-2103-c cc3. 530 --O2G
Does applicant reside on prope ,3, Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
Y6S ❑No (counting just the homestead site for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999(all Indiana real
property]for the i�/xv rea initially applied for after December 31,2019.)See reverse for detalls.
Is the applicant 65 years of age or more on December 31 of the ye
Have you filed for any other deductions? If Yes,what deductions?
1314S ❑No PIP 5, I-loeneS}er.z(
Have you filed for deductions in any other count ? If Yes,what county?
CD yes FEB 1 2022
I/We certify under penalty of perjury that the above and foregoing information is true and correct. /v / r l/
Signatrm'M applicant GIE�� ee� ITOR
Address of applicant (number and street,city,state,and ZIP code)
a, G ► 1 ►v . P o,l K 5 V . 'F"'Jr• C3 r o.:I-%c n S Y, LA-i Le 1-4 $
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signatpretof Coun ditar 4 -11/ Date(month,day,year)
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer