Age_Sullivan ►
.4— a,� APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�,re li PROPERTY TAX BENEFITS
i,kState Form 43708(R 15/1-20) 16500 (CIU otbta d
J Prescribed by the Department of Local Government Finance
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(Ple e the all that apply)
Over 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Name of applicant(owner or contract Myer)
Co( e. N. 5u It;vf~v'
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.
EI''es ❑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?
Dyes ❑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? e"t'e5 ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
[-al property ❑Mobile home(IC 6-1-1-7)
Taxing district \� Key number/Legal description Record number Page number
Colosa 0(0-13-1 .-a00-00t. U3-1-COCo
Does applicant reside o rop ? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or S199,999
Y6S ❑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
$
individual's spouse.)See reverse for details.
Have you filed for any other deductions? If Yes,what deductions?
UJx s ❑No I-(O s+eo.-d
Have you filed for deductions in any other county?ty If Yes,what county?
Eyes LvJrto
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Date(month,day,year)
Address of applicant (number and street,city,state and ZIP code)
c951 N II so E 150lb.r.d Ci t, 447 Co 6 fJ
Sign re of authorized represen tivers Date(month,da year)
Address of authorized representati a number and street,city state,and Z Q.)
?<) -- �1 0 e_ S± j vw(-A-6Y) - `I-70
Signature of County Auditor� _ Date(month,day,year)
Jt. �� 0-7Yy a a
FILED
MAY 4 2022 .! ' /
iy1l�lou( a.1/1� y
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer GIBBON COUNTY AUDITOR