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Age_Robb *.a, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR .7�` PROPERTY TAX BENEFITS } ,_ State Form 43708(R15/1-20) �;hson (-h�.z(� ,� 5 r Prescribed by the Department of Local Government Finance , ,w 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 Type of benefit requested(ilee`s°check that apply.) .� ,,�.-�' \ Over 65 Deduction from Assessed Valuation 1:141: ver 65 Circuit Breaker Credit Name of plli/ica_�nt((owner or contract buyer) P(� � Is appli nt the sole legal ore stable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom. ❑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? es ❑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? Yes ❑No Address of contract seller(number and street,city,state,and ZIP code) Is the pr rty in question: eal property El Mobile home(IC 6-1-1-7) Taxing district Key number/Legal description Record number Page number 1-16LZ.Ie10,1 a4-0 -yq-lo(-r)oa. (55 --©/7 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 r��/es No [counting just the homestead stte)for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Ind iana real t_� ❑ property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details. Is the applicant 65 years of age or more on December 31 of the year individual's spouse.)See reverse for details. Have you filed for any other deductions? If Yes,what deductions? / AA Dr❑No Ho► ies4-eod, ✓Voc4-j'€- Have you filed for deductions in any other c�o�upt-t? If Yes,what county? ❑Yes IJ No I/We certify under penalty of perjury that the above and foregoing information is true and correct. qaM ture of applicant /V L'"-"t/� Date(month,day,year) ss of applicantnumber and street,city,state,and ZIP code) I43 Al 7ennesseee JJ RIX.Z.)145i1 .Tit/ Ll 260 ya Signature of authorized representative Date(month,day,year) Address of authorized representative (number and street,city,state,and ZIP code) Sig atur of CountvAud't r Date(month,rdtay,year)t ppI,�611 `' a . /($. FILF D MAR 0 2 2022 GIBSON COUN T v rsuDITOR DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer