Age_Collins (2) �.� ',v, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
y PROPERTY TAX BENEFITS /t /���7"(��,J'� }�
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�"'' '• StatesForm 708the epaR15/ ent \ �,,� N_ (Z �,`y`" -" 1 ;)�.
7Ti-.d Prescribed by the Department of Local Government Finance �J r\ 'I�{:4 .r:
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
`
Type of benefit requested(Please check all that apply.)
1105v D st. n from Assessed Valuation Likergr 65 Circuit Breaker Credit
Name of applicant(owner or contract uyer)
.. ---a-1 rt\e - CI- irk ‘V x Y1S
Is applicant the sole legal or equita le owner? If No,wh t is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
es ❑No
If name on record is different than that of appiia.ei if.indicate below. Do all joint tenants or tenants in common reside on the property?
[1'f€s ❑No
Name of contract seller Has applicant owned or been buying the property under recorded contract for
Pt- at least one(1)year before claiming deduction? Eloyeg" ❑No
Address of contract seller(nuiNber and street,city,state,and ZIP code) Is the pro in question:
eal property ❑Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description I Record number Page number
Pr'\ nr e_AC>(1 oZu-.) - \ -O -1AO-, -I �c�$,
Does applicant reside on property" Assessed value of the property as of current year assessment date(May of�e�2W,000 for Over 65 Deduction or$199,999
es ❑No (counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999 fall 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 of age or more on December 31 of year
'
Have you filed for any other deductions ' If Y�es�,`w t deductions? �,, (� �/�
LSl�es ❑No `Y v� ( c>�-l� i 1� \ \ \ R ,
Have you filed for deductions in any other county? If Yes,what county? f
❑Yes -
I/We certify under penalty of perjury that the above and foregoing information isrtrue and correct.
—
Signal re of applicant r " I '�n Date onth�d7ay,year
4.41
Add ss of applicant (number and street,city,state,and ZIP de)
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of County Auditor Date(month,day,year)
FILED
MAY 2 2022
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GIBBON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer