Age_Reed c
gl , APPLICATION FOR SENIOR CITIZEN cUNTY TOWNSHIP YEAR
a PROPERTYTAX BENEFITS
1p State Form 43708(R15/1-20)
1� Prescribed by the Department of Local Government Finance 9 S�• , O2c 2 -
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.
\
Type of benefit requested(Please h ck all that apply) ` `
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or con ac buyer)
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.
El Yes El No
If name on record is different than that of applicant,indicate below. Do all joint tenants or tenants in common reside the property?
Yes ❑No
Name of contr t s r 17-eC__,C Has applicant owned or been buying the property under r or d contract for
at least one(1)year before claiming deduction?
Yes ❑No
Address of contract seller m r d street,city,state,and ZIP code) Is h property in question:
Real property El Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal descri tio�i ` Record number Page number
Z�o 26'_'1°\-\ -D 4 c oo 113� —02
Does applicant reside on pr y? 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 Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years age r more on Dece er 1 of the year
I/We certify under penalty off/perju (
u (��that the above and foregoing information is true and correct. {{}
\/Signatur pplicant 6 Date n h,(aytr) �
A ress of applica t ( u er and street,city,state,artt,ZlP code)
V2 T- I 0 - j3 ►u.� St- - _ -v".cIn-->ifl- 1l9' 6 4 Y , LLL
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of Audit r Date5oT. r
t.
FILED
A U G 1 7'2/0�22
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Ta� � J it- e>r J
bN COUNTY AUDITOR