Age_Deboard -=*,, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
°� �" PROPERTY TAX BENEFITS
l 0 �s` �� State Form 43708(R15/1-20) Ot��1/\
• Prescribed by the Department of Local Government Finance 1
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 all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or cont ct uyer) r,,v t ��\�
Is applicant the sole legal r equitable owner? If what his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
Yes ❑No IIIJJJ
If name on record is differ nt han that of applicant,indicate below. Do all joint tenants or tenants in common rest�,o��he property?
es ❑No
Name of contract seller Has applicant owned or been buying the property unde rec rded 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 th property in question:
Real property ❑Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
%-1 l-I l- ,___ CO-CD OIL 040-02-g .
Does applicant reside on p erty? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
Yes ❑No [counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
property]for the Over 65 Circuit Breaker Credit initially applied for alter December 31,2019.)See reverse for details.
Is the applicant 65 years a or more on December 31 of the year
single return;or(2)$40,000 for individuals who filed a joint return with the
individual's spouse.)See reverse for details. TOTAL $
Have you filed for any other de u ions? If Pest what dddeee���uucctions
,d/y�,I{�,tYes ❑No 111\• �- 1 „ ��W rnn�
Have you filed for deductions ifi dOy other o iupty? If Yes,what counntty'?✓✓✓
❑yes No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
gn lure of applicant Date nth,day,year)
!�/��/\S � Z-
Addres applicant (number and s reet,city state,and ZIP cede) ,
32.i4 r1n� 9,�� lh -Dh- u9-6
Signature of authorized representati i Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code) tt
Signature of County Auy(tpr / Date( h' ay,ye
�(`V 1 J �J\ 2'� �
FILED
MAY 5 2022
ate )
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer GIBSON COUNTY AUDITOR