Age_Torres APPLICATION FOR SENIOR CITIZEN
��,-`1�4, COUNTY TOWNSHIP YEAR
- PROPERTY TAX BENEFITS
�'
% State Form 43708(R15/1-20) // OU-1C ^
'• d. Prescribed by the Department of Local Government Finance v(b Son CA f-I 0 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
/
Type \`e'% . r u e ase check all that apply)
( e Et-Kier r 65 Deduction from Assessed Valuation 65 Circuit Breaker Credit
Name o applicant owner nr .nntrnrt huver)
K- -75rres
Is applica a sole legal o uitable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
QXtfs ❑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?
s ❑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?
❑Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
rL`.. <eeal property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
c �1 c•..d C i F-y a 6-I H-19-(Do/-coo, 710 -cxc-7
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 6i5 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
property]for the Over 65 Circuit Breaker Credit initially applied/or after December 31,2019.)See reverse for details.
Is the applicant 65 years of age or more on December 31 of the year
$
Have you filed for any other deductions? If Yes,what/deductions?
L1io/Yes ❑N Hit 1. lts_}"e r—
Have you filed for deductions in any othe ty? If Yes,what county?
Oyes No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature applicant Date(month,day,year)
Address of applicant (number and street,city,state,and ZIP code)
14{8 S -5oii,se , 00,4 c,,4 C1 `3 7-i✓ g7G(o 0
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code) T T T
Signature ofi .' County Audi r ,- . --/. / Date(month,day, )1 Lt E ■T/
L
JUN 21 2022
GIBBON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer