Age_Elpers +,t_ .1*.4 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�%- `e PROPERTY TAX BENEFITS I>'� v' State Form 43708(R15 1-20) 6I b50h f4µVjV SfPC1 as
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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. ,��/
Name of applicant(owner or contract buyer)
_ AI;ne E fpel- C''tc o&c ate)c..0
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.
-'i s ❑No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common reside on theproperty?
le"Tes ❑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? LrJ re5 ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is the ,frreperty in question:
liEikeal property ❑Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
f/aubs di- a6-t8-36-4l0 q-CO0-09 0- 009
Does applicant reside on property? 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 Broker Credit initially applied(or after December 31,2019.)See reverse for Betails.
Is the applicant 65 years of age or more on December 31rof the year
Have you filed for any other deductions? If Yes,what deductions? /�
E rTes ❑No t.lowx_sa S} t .S-
1`r�0 r k y q P
Have you filed for deductions in any other cou v If Yes,what county?
❑Yes al No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant az Date(month,day,year) - '<3,
Address of applicant (number and street,city,slat and ZIP code) .S 2 3
COO( ) L fM 5f. a-l&I,>>b S4-ce F :z &J Y76 3 9
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 3 2022 ��
1� )
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer GIBBON COUNTY AUDITOR