Age_Cornwell .-..•,.. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
.7�_•"' PROPERTY TAX BENEFITS
}*\, State Form 43708(R15/1-20) [ 1 b 5 c
";e„�--i'" Prescribed by the Department of Local Government Finance lJ �1 I)r(4ct f 0kt
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. FILED
See reverse side for additional instructions and qualifications.
Type of benefit requested(Please check all that apply.)
Over 65 Deduction from Assessed Valuation Easatre'r 65 Circuit Breaker Credit FFR 2 3 2022
that of applicant,indicate below. Do all joint tenants or tenants in common reside on the property?
E l'es ❑No
Name of contract seller Has applicant owned or been buying the property under record 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�the,property in question:
[(,.Real property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
Pr►nc-Qfoh ,.D4-ifa-a6- aoa-003. Ltoq- a 0 g
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
[; es ❑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 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 f the year
Have you filed for any other deductions? If Yes,what deductions?
[L-Vds ❑No PO04es7 ear,/
Have you filed for deductions in any other county? If Yes,what county?
❑Yes FQ-KO
I/We certify under penalty of perjury that the above
Address of appli nt (nu''and street,city,sta e,and ZIP code)
303 wallowfie kl . (arlr'tcetout 1/l/ 4171P 7U
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Sig atur f County Auditor ., ----1 / Date(month,day,year)
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer