Age_Banet �s^�r•,, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
4% ` PROPERTY TAX BENEFITS
-!" It State Form 43708(R15/1-20)
. Prescribed by the Department of Local Government Finance O'r- , O 1R---- ! 4C;)22
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 chec all that apply.)
Over 65 Deduction from Assessed Valuation I JCI Over 65 Circuit Breaker Credit
Name of applicant(owner or con act b er) JT\
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.
❑Yes ❑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?
❑Yes ❑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? El Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is property in question:
Real property ❑Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
��� - Z6 -OG-OC,-7-oo -000, S S -0 f9-- '
Does applicant reside on p p rty? 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 fall Indiana real
df/ a�l7 property for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years ag or more on Dec ber of the year
$
Have you filed for any other deduc ions? If Yes,w at deductions?
es ❑No Vi j /2\c1 -
Have you filed for deductions in any other cou ty? If Yes,what county?
El yes No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
XSig - re of r.licante J Date(month,logy, ear)
Ad.-.f applicant (number and street,city,state,and ZIP code)
-7 i' NI .S'L-6
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of Cour}(y,}ludite _ c Date(month,dal year
(I y 11 V 0 3 -1-•3 Z L___.
FILED
OCT 3 2022
Yh,,- << a..1/� ,ev,.)
GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer