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APPLICATION FOR SENIOR CITIZENlPROPERTY TAX BENEFITS /co/uNTY TOWNSHIP YEAR
�� State Form 43708(R15/1-20) G lb 5o n To-kk�
`,' Prescribed by the Department of Local Government Finance "7 W n a;,
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 that apply)
E ver 65 Ded ' n floor ASsegsed Valuation IS-Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
t o-nv-t.e N L tj o f w,o. S VAI\k
Is applicant the sole legal or equitable owner? If No, exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
I r 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?
[,ZI�eS ❑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?
❑' CI No
Address of contract seller(number and street,city,state,and ZIP code) Is the prgperty in question:
rL—n1eeal property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
PG�34-.- Twvf s he -oq cif-3r), -ram, v/?-Dao
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
LiA/.es ❑No [counting just the homestead site]for the Over 6i5 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
Ltd7" property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for detaifs.
Is the o applicant
the antyea 65x5 esars of ar firs e doe r m mond re on Deecember 3 f the year �,
/
Have you filed for deductions in any other county? If Yes,what county?
CI Yes jJ.Wo'
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature• applicant 2�_�_ r r Date(month,day,year)
t��. s'Gi ���i ' c--� ,VO£i t 4-r,7"u ive 10/T c)W-r/ - Z
• s of applicant (number and street,city,state,and ZIP code)
31 O ,1\) (1(Vr.w-;n 5 t- Pc-t. KL- :TA) 4/76 6 L
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signattre of unty Auditor Zt� ,� Date(mn/,year) z
FILED
JUN 01 2022
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer .Vhf.2G(Q,1/�t ,;n,„)
GIBSON COUNTY AUDITOR