Age_Dunn �,,,,. •r., APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
�% �1; PROPERTY TAX BENEFITS ��//JJ �7
'� i1 State Form 43708(R15/1-20) �/ C O_/1 ��� /.('1��
___ Prescribed by the Department of Local Government Finance lio ,_.
•-.. 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.)
t.Lfvvrer 65 Deduction from Assessed Valuation er 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
Is applicant the egal 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.
T.-WC' ❑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?
Dyer' ❑No
Name ofY�contract\ seller Has applicant owned or been buying the property under recorded contract for
Y at least one(1)year before claiming deduction? ❑No
(-'
Address of contractr es seller(number and street,city,state,and ZIP code) Is the property in question:
eal property ❑Mobile home(IC 6-1-1-7)
Tax district Key number/Legal description Record number Page number
fr't Ir\r e_ -- t�lo - ( a-o7 -` 00 ( T7c (_ul,t.�-(-).- ci" .
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
es ❑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 Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years of age or more on December 32...pf the year
Have you filed for any other deductio ? If Yes what deductions?
VIWes ❑No `
Have you filed for deductions in any other county?� If Yes,what county?
❑Yes LSIrvo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Date(month,day,year)
4-‘GFa 7� `. 11 r_ `7_,a 2.'i
Address of pplicant (number and Atreet,city,state,and ZIP code) 10
Signature of authorized representative / Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Sign ture of County Auditor Date(month,day,year)
FILED
JUL 0 5 2022�> -
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer
GIBBON COUNTY AUDITOR