Age_Shipman /4417 *:4, APPLICATION FOR SENIOR CITIZEN cpUNTY TOWNSHIP YEAR
i(°' {� PROPERTY TAX BENEFITS I /1/ //��/�
\\a�s���� 1' State Form 43708(R15/1-20) Ste,` 0 / 4 1, �./?7
Prescribed by the Department of Local Government Finance [/ lV\ -
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS: To be riled 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. // '
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Over 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Name of applicant(owner or con ac uyer) '
Oh CIA)
r n`'
Is applicant the sole legs r e table owner? If No,what is his/her exdct share or interest? If owned with joint tenant or tenant in common,indicate with whom.
Yes ❑No
If name on record is dill rent han that of applicant,indicate below. Do all joint tenants or tenants in common reside n e property?
es ❑No
Name of contract seller Has applicant owned or been buying the property under r o 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) Is roperty in question:
Real property ❑Mobile home(IC 6-1-1-7)
Taxing district KeYnum /LegaLdescription �0 _ Record number Page number
Does applicant reside on p p y? Assessed value of the property as of current year assessment date(May not exc ..1$200,000 for Over 65 Deduction or$199,999
Yes ❑No lcounting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999 fall Indiana real
mperly]for the Over
individual's sp•••j�- See revere for details. ►/�y�t�
Have you file J�Ither de u ons? I If Yes,wha deductions?t 1 '
t Yes .�No S
Have you filed lions ny oth v ? If Yes,wha county.
❑Yes r.No
I/We certify under penalty of perj ry th-t the above and foregoing information is true and correct.
.gna ure of applicant Dattmo 1 dayie�r)r2 r�
16.44/
A�s of applilican n `ands eet,city, ate,and Zli...t)
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l vv �Signature of authorized representative / Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)93)
Signature of County Auditor r- Date(rgonth, al Syepr) �2 2_ ,
1
w �is clh1\
FILED
APR 1 3 2022� )
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer /LtZGZ a.,. d
GIBSON COUNTY AUDITOR