Age_Page APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
%'' PROPERTY TAX BENEFITS O� O�C� \°
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1,1 State Form 43708(R15/1-20)
%/ Prescribed by the Department of Local Government FinanceTe-- .
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.
See reverse side for additional instructions and qualifications.
Type of benefit requested(Plea�e,cch{ec_k all that apply.)
y�ever 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Name of a nt(owner or con/tr�e{�buyer�� >� /
If owned with joint tenant or tenant in common,indicate with whom.
es ❑No
Do all joint tenants or tenants in common reside on the pro erty?
If name on record is different than that of applicant,indicate below. es ❑No
Name of contract seller Has applicant owned or been buying the property under recorded act for
at least one(1)year before claiming deduction? es ❑No
Address of contract seller(number and street,city,state,and ZIP code) I e property in question:
it---
Real property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description I
Record number Page number
Q en.Slir f l� 2 -1 e- 0-7— Imo• CQ— r)
Does appli reside on grope Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,9ea
(counting just the homestead site]for the Over 65 Circud Breaker Credit received before January 1,2020,and$199,999[all Indiana real
Yes ❑No 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 a year
individual's spouse.)See reverse for details
Have you filed for any other deductio . If Yes,what deduction?
❑
es No 71 ! Z----'
Have you filed for deductions in any other county s,what county?
❑Yes
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
IDate(month.day,year')�� /J
yignature of apt nt - // ear) /�JddL./
re/ss of appl nt (n� r and street,,city,stp
d cede) ,t �7� f ("—�
7 P. (,fa `'"" f X//�C//Q ( (1 Datete(month,day,year)
Signature of authorized representative
Address of authorized representative (number and street,city,state,and ZIP code)
",/ I Date(month,day,year)
Signatur County ud r �/f C2 r '� _�ll �FILED
APR 11 2022
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer L yIC & % �
GIBSON COUNTY AUDITOR
