Age_White APPLICATION FOR SENIOR CITIZEN CUNTY TOWNSHIP YEAR
7�/��,f�4= PROPERTY TAX BENEFITS ,i,„
sIr State Form 43708(R15/1-20) oZ� ,)`Zz_
.„ d" 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
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Na of applicant( w ose{r con a buyer) ��<�
•
sol legal or equitablewner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
❑Yes ❑No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common reside o the property?
Yes ❑No
Name of contract seller Has applicant owned or been buying the property under r ed 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 t property in question:
eal property ❑Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
2-6 --oc‘--24-3r)4-000 \Zl -vv3
Does applicant reside on open Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
Yes ❑No (counting just the homestead site]for the Over 6i5 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 year of a e or more on December 31 of the year
$
individual's spouse.)See reverse for details.
Have you filed for any other de ions?
X__ If Yeha�eductions?
Yes ❑No
Have you filed for deductions iy othe nty? If Yes,what county?
❑Yes No
I/We certify under penalty of perj at the above and foregoing information is true and correct.
\r Siture of pplican Date(month, y,year) 9
Address of pp scant (number and street,city,state,and ZIP code)
loot I.-.-: VCnt St- ({AA ► c - 3Y)-
Signature of authorized representative Date(mont ,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of Cou/'igi dit Date(mrSidenale,10 2:2_
4,11\
FILED
MAR 2 2 2022
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DISTRIBUTId#IPK r{aIDIMtSr y TPRFile-Stamped Copy-Taxpayer