Age_Critchfield i
Mom ,, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
„felt. PROPERTY TAX BENEFITS 2
` jam,, State Form 43708(R15/1-20)
SoA 0a �oz_
'y "' 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 first due and --, ��
See reverse side for additional instructions and qualifications.
Type of benefit requested(Please check that apply.) ��-r/
L
Over 65 Deduction from Assessed Valuation �/ Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer) .Z.., ��,'��(/ �� J C
Is applicant the sole legal or equita a 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 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 the perty in question:
eal property ❑Mobile home(IC 6-1-1-7)
/� Key number/Legal description Record number Page number
a� ea -.33 - Roo Tr/s./ ,a&'r�distri _ o 0 0 . 5 3 1-o A `7
Does applicant reside on o Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
(counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999(all Indiana real
Yes ❑No grope j for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years or more on December 1 of the year
$
individual's spouse.)See reverse for details.
Have you filed for any other deductions? If Yes,what,dedu�tions?
es ❑No /Ly/ 5
Have you filed for deductions in any other ccounty?'ff Yes,what county?
❑Yes L"fNo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signatu of applicant /n �(o� Date(month,day,year)
`� — �'' -tiLi v le Le,•^ode
f Address of applicant (number an:street, ity, -- - 7i'• ) ti, �j',,
Date(month,day,year)
Signature of authorized representative
Address of authorized representative (nu •er and street,city,state,and ZIP code)
Date(month.day,year)
Signature of Count Auditor f( /�
7,,,...
FILED
APR 12 2022
a er GIBBON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor: File-Stamped Copy-Tax p Y