Age_Bilderback . •'� ,, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
a PROPERTY TAX BENEFITS I
State Form 43708(R15/1-20) (`‘1) (9� �^
*: Prescribed by the Department of Local Government Finance V (—
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
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(o or con` \` � r•( VVV
Is applicant the sole legs or equitable owner?( 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 resid o the property?
Yes ❑No
Name of contract seller Has applicant owned or been buying the property under 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) I he property in question:
Real property ❑Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
26- 01,4 ZS=1b 1-oo0.O61 -Oz-
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
Bunting just the homestead
_�C d ,A"�'//''tt
Yes ❑No \ t \ -�I� Cam)\� `r--f),
Have you filed for deductions' an they nty? If Yes,what county? /!
❑Yes No
I/We certify under penalty of perjury t t the above and foregoing information is true and correct.
' Si �t ture of applicant_ ` t2.katdvsz Date(month,layleartisozz_JX\ drress of applicant ((nuumberrraa)nd street,cit state,a d ZIPcod )
G Svc Mi\\ S `lt,. 1-Cc. — n-tin 6 6 6
Signature of authorized representative / Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
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Signature of my Aud'or Date(morrh,clay,learTrsc _ z
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FILED
C APR 08 2022
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, .ed Copy-Taxpayer L.c.,
C GIBSON COUNTY AUDITOR