Age_Cook ,...,-*�r.a APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
��- 1-- PROPERTY TAX BENEFITS
7t I: State Form 43708(R15/1-20) ��
'+` � Prescribed by the Department of Local
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.
Type of benefit requested(Please check all at apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or contract bu er)
3-e rfy Coo Il—
ls 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.
lai-Yg- ❑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?
❑Yes ❑No
Name of contract seller Has applicant owned or been buying the property under recorded 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 the pro erty in question:
eat property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
3 n .G—ao—Oa— aol-O0o.$) - oo I
Does applicant reside on property?rr��,,ty/ Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
lyres ❑No [counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[alI Indiana real
property)for the Over
individual's spouse.)See reverse for details.
Have you filed for any other deductions?r-,� If Yes,what(deductions?1,, r
t�Yes ❑No HO All a 5+er:i.1
Have you filed for deductions in any other county? If Yes,what county?
❑yes E ftjo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant C ck`�in I _ Date(month,day,year)
v — S= 2 o z Z
Address of applicant ber a street,city,state,and ZIP code)
SigrZure of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of Co my Auditor Date(month,day,year)
FILED
MAY 5 2022
`7`'Lec DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer c &.1/Y2�`.�i:ffd) /�/
GIBSON COUNTY AUDITOR