Age_Tooley a• ;*. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
\�, [._I,E State Form 43708(R15/1-20) ��tt\ (�2F-
+ •'/• Prescribed by the Department of Local Government Finance —1�Ofl � l
\J, 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
Type of benefit requested(Please ck all that apply) \
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicantowner'e4 con a buyer)
Is applicant the sole legal orequitable o r? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
El Yes ❑No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common resid= o. he property?
Di Yes El No
Name of contract seller Has applicant owned or been buying the property under r .4, ded contract for
at least one(1)year before claiming deduction? -1 Yes El 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)
Taxing district Key number/Legal description Record number Page number
d , _ 26-21 3Z 3o "lo o •E6q-oa .
Does applicant reside on prope y? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
es ❑No (counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999 fall Indiana real
property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years of or more on Decemb r of the❑year
Yes No S
Have you filed for deductions iother co ty? If Yes,what unty?
❑Yes o
I/We certify under penalty of perjury tha the above and foregoing information is true and correct. t
Signature of-,'applicant
�^'c '' Date(mon , day, ar)
X .t7- -- -
Address of applicant (number and street,cit stat$,,and 2IP de) ^IAi //'^ 1vt1 (_�l
joI cr � l/ llSgnature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of CpVt udi CID Oatth,d ea
FILED
APR 14 2022
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer
GIBSON COUNTY AUDITOR