Age_Burns -,,.• •*.,, APPLICATION FOR SENIOR CITIZEN c t�yNT� r r S�IP� YEAR
y/- l' PROPERTY TAX BENEFITS --1 1 L r ,� 1 J)
� , State Form 43708(R15/1-20)
's\._ -- Prescribed by the Department of Local Government Finance n'
APR 01 I2ifftii1ark
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 propertyGd�Q Y o
AUDI
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
Type of benefit requested(Please check...pH that apply) �� ��
Ee-over 65 Deduction from Assessed Valuation L'I'dver 65 Circuit Breaker Credit
Nam*pplicanr contract buyer)
Is applicant the sole legal or equ, le owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
❑Y ❑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?
El 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? ❑Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is the pjpperty in question:
...Areal property 0 Mobile home(IC 6-1-1-7)
Taxi districtKey number/Legal description Record number Page number
a & _ IX _0 -7 . o2oy - 000. ,Z43 - oz8
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
❑Yes ❑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 detal/s.
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?du/ If Yes,what deductions?
E r�es ❑No /.{ 5 /Yl ✓
Have you filed for deductions in any other county? If Yes,what county?
❑yes IDN0
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
kSignaturee off applicant Date(month,day,year)
C J0c:„.t,, ,� y — /— 2 2—
`X/ Address of applicant (num and street,city,state,and ZIP code) ,,
` �P o C E.� 12rs6it Sr /YI'a,c'e Tart, .4 ✓v' 9 '?to7 C
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of County Auditor "'� tig Date(month,day,year)
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer