Age_Grubb
4s srefx APPLICATION FOR SENIOR CITIZEN COUNTY T NSHIP YEAR
} PROPERTY TAX BENEFITS ( Aft.b7-7----
rEile' LS State Form 43708(R15/1-20) t�^ii i� Prescribed by the Department of Local Government FinanceV Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. T Mark
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is locatM,s 204,
ON
Filing Date: Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the0'/Qegrltgli/
January 5 of the calendar year in which the property taxes are first due and payable. / qU
Of TOR
See reverse side for additional instructions and qualifications. rr
Type of benefit requested(Please ch k all that apply.)
•ver 65 Deduction from As ssed Valuation L� ver 65 Circuit Breaker Credit
NamCpplicantrzer or contrituyer) r •
1 i
Le)Z‘Le_162_,
Is applicant the sole legal or equ.able 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? ❑Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) `Is the roperty in question:
Real property El Mobile home(IC 6-1-1-7)
Taxi district` /
$
individual's spouse.)See reverse for details.
Have you filed for any other deductions? If Yes,�what deductions?
/
SI-Yes ❑No /-- t "it1 7"ff
Have you filed for deductions in any other county? If Yes,what county?
Oyes '9].11o
II/VVe certify under penalty of e ry that the above and foregoing information is true and correct.
` I$grl�(ture of a nt Date(month,day,year)
Adc(F e�15go ��er nn�� et-city,stafp, nd IP c de�� �� 7
Si/-/X/rtf/etI/Irr/e of authorized re ssentlltatitiive f//\•a/`'l¢/.ill J� Date(month,day,year)
Address of authorized representative ( mber and street,city,state,and ZIP code)
Signatu o Coun Audit Date(month,day,year)
FILED