Age_Burkhardt ,,.;Et:q APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS �� Q ����/7
(1,41,
State Form 43708(R15/1-20) TO
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� Prescribed by the Department of Local Government Finance �w .
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
Over 65 Deduction from Assessed Valuation JQI Over 65 Circuit Breaker Credit
Name of applicant(owner or co rac uyer) kANI k�^ Ca—
/ 1
•
Is applicant the sole legal or equitable owner? If No, t 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?
CI Yes El No
Name of contract seller Has applicant owned or been buying the property under rec red contract for
at least one(1)year before claiming deduction? Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) I hA property in question:
/L}di\IS Real property ❑Mobile home(/C 6-1-1-7)
Taxing district K num r/Legal description Record number Page number
02--g - -12-18-102-000 -2;10 -022 •
Does applicant reside on pr pe ? Assessed value of the property as of current year assessment date(May not excf$200,000 for Over 65 Deduction or$199,999
❑No [counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199.999[all Indiana real
es property]for the Over
es ❑No SHave you filed for deductions iother c `' ty? If Yes, hat county?
❑Yes o
I/We certify under penaltyof perjury that the abov and foregoing information is true and correct.
Signal o pplicant / / Date(month.day,year)
Address of a nt nu ,rr and street city,stat a IPe)
,n - Dfl- t-)1--6 9-o.
Signature of authorized representative j d pod Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of CodcWril 'to — @ Date n ,day,year ) r_
) ( •
FILED
APR 252022
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DISTRIBUTION: Original-County Auditor: File-Stamped Copy-Taxpayer GIBBON COUNTY AUDITOR