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Age_Druley �..�•*.,, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR A - `A PROPERTY TAX BENEFITS 5' _ '�.1 State Form 43708(R15/1-20) //,`, rL /�—��7 ' `-� Prescribed by the Department of Local Government Finance v t�5�^ /'T. "( c/1 w L !— 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 Type of benefit requested(Please chec I that apply) Over 65 Deduction from Assessed Valuation atl<r 65 Circuit Breaker Credit Name of applicant(owner or 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? Eric ❑No Name of contract sell Has applicant owned or been buying the property under recorded contract for at least one(1)year before claiming deduction? et-Yes ❑No Address of contract seller(number and street,city,state,and ZIP code) Is the larpperty in question: eat property ❑Mobile home(/C 6-1-1-7) Taxing diei" Key number/Legal description Record number Page number -t---- \ . o--,ti_,c DAZ - ( g -\,_q.- LA -oo C - -- 3 (4 -©.D-C2 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 Elves El No Have you filed for deductions in any other county? If Yes,what county? ❑Yes ❑No I/VVe certify under penalty of perjury that the above and foregoing information is true and correct. Sinatur-r applic-nt kin/ - p Date(month,day,year) Address of applic, t (number and street,city,state,an ZIP code) , "'1 \ i� 1 L 1`-- —`t---0-_,--, I �� Q Signature of authorized representative / Date(month,day,year) Address of authorized representative (number and street,city,state,and ZIP code) Signature of County Auditor Dat ' Date/(month,day,year) `� `\,_6 9--,0�-4- (A. -V-Th Cam , A�/ _rY`� — Zk—Z -- F ILED SEP 2 1 2022 .fr\--)' -\_,.(__ . i ,4 a.j/�exke,to) DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer GIBBON COUNTY AUDITOR