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-,_i w APPLICATION FOR SENIOR CITIZEN COUNTY WNSHIP YEAR
a PROPERTY TAX BENEFITS To
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State Form 43708(R15/1-20)
- Prescribed by the Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. 41 2022
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is 07
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Filing Date: Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the�/dl/Ltyi
January 5 of the calendar year in which the property taxes are first due and payable. D/TOR
See revers side for additional instructions and qualifications.
Type of nefit requested(Please the all that apply.)
ver 65 Deduction from Assessed Valuation X3ver 65 Circuit Breaker Credit
Name applicant( gn or contract b r) AL)�
(215
Is applicant the sole legal or fable owner? If No, t is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
1XYes ❑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?
❑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 th property in question:
Real property ❑Mobile home(/C 6-1-1-7)
T. i riot Ke number/Legal escription Record number Page number
-05--5 ,../ 40-•COOa•4=.2a— as 7
Does applicant reside on p perty? 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 a/ter December 31,2019.)See reverse for details.
Is the applicant 65 years f age or more on December 31 of the year
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individual's spouse.)See reve se for details. `
Have you filed for any other de c• If Yes, fS de ttio ?A 6f/
ivl
Yes ❑No }� 3
Have you filed for deductions in a other county? If Yes,what county? /� �, • z.
? / /�
❑Yes XN -!�o /7�� . �J l6) � 9s� /�
IJWe certify under penalty of perjury that the above and foregoing ormation is true and correct.
4 Sig lure of applicant Date(month,day,year)
Address f ap icant (number and street,city,state, ZIP/code)
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Signature of authorized representative Date(month,day,year)
Address of authorized representative (numb r and street,city.state,and ZIP code)
Signa a of ounty uditor r Date n�" ar
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FILED
APR 11 2022
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer /7`Y ..uk,, %cglq
GIBSON COUNTY AUDITOR