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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