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Age_Schmitt <•.-. _: APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�': PROPERTY TAX BENEFITS , �/Y�)/y�
State Form 43708(R15/1-20) COUNTY
CO \ ^�� _
:'' Prescribed by the Department of Local Government Finance • \ (^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 auditor or postmarked by the following
January 5 of the calendar year in which the property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Over 65 Deduction from Assessed Valuation L�Over 65 Circuit Breaker Credit
Name of applicant owner or con rG e_r) /
Ci'-k3 l•_tv�t
Is applicant the sole legal or equitable 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?
Eyes ❑No
Name of contract seller Has applicant owned or been buying the property under rec r d contract for
at least one(1)year before claiming deduction? I�rtr es ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is tb property in question:
Real property ❑Mobile home(IC 6-1-1-7)
Taxing district Key umber/Legal descri tion Record number Page number
01°C, _ 2�-Z3 -e6- o-cfoo_S15--00'1 _
Does applicant reside on pr��_��-eyyyyyy[[[[[[y? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
s ❑No [counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1i 2020,and$199,999[all 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 o age r more on Decemb r 1 of the year '
$
individual's spouse.)See reverse for details.
Have you filed for any other deduc ions? If Y s,what deductions?
c'es ID No S .
Have you filed for deductions any other c,�oou,}}`ly? If es,what county?
❑Yes Ly No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.X Signature ofpplicant DateLl�2_6 year)
Address of applicant (num rand street,city,state,and ZIP de
52k-. , G5� �— -r1- La 9-G3g
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code) 1 r�
Of\ /� Date rr�n��y y G 2
Signature of County Auditor \J`�— v 't f—(]l I I
FILED
APR 2 6 2022
Y274,„,,..„..,.." a 1 .. rtd)
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer GIBBON COUNTY AUDITOR