HomeMy WebLinkAboutAge_Lee (3) APPLICATION FOR SENIOR CITIZEN
� 'q• COUNTY TOWNSHIP YEAR
44i.
4 , _ 11 PROPERTY TAX BENEFITS ^ Z 2
State Form 43708(R15/1-20) O/ 2,0's ,e1i I' Prescribed by the Department of Local Government Finance 1
, ..sc.ti rV 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
Type of benefit requested(PleaseXk all that apply.) ('
ver65 Deduction from Assessed Valuation 17�Over 65 Circuit Breaker Credit
Name
owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
Yes ❑No
If name on record is different t n that of applicant,indicate below. Do all joint tenants or tenants in common resid on the property?
Yes ❑No
Name of contract seller Has applicant owned or been buying the property under a rded 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 t property in question:
eal property ❑Mobile home(/C 6-1-1-7)
Taxing district 006�_ Key "tuber/Legal description
-►3-26 -300-000 Ltgp -oo6 Record number Page number
Does applicant reside on property? Assessed value
TOTAL $ \J
individual's spouse.)See reverse for details.
Have you filed for any other de tions? If Yesi'what deductions? ...,....1-Yes ❑No ' _ Nai
-t \
Have you filed for deductions in any other o `'ty? If Yes,what county? `,V
❑Yes YU No
I/We certify under penalty of perjurythat the above and foregoing information is true and correct.
Signature applicant Date(month,day,year)
Address of applica t (number and street,city,state,and IP code)`
3244 s ot5o C.- �J plla„d a _code)
1-1+CCfl .
Signature of authorized representati'e Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of County Auditor 1 •1‘ND Qq)
Date(mon►Ih�dsy ear)
,Ls -^tT l
FILEP7 7
5...,
JUL 2 7 2022
GIBSON COON' OR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer