Age_Abney j -z.,, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
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�` State Form 43708(R15/1-20) V SOI'I of
\ ', Prescribed by the Department of Local Government Finance
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
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I -PlVer 65 Deduction from Assessed Valuation I -e r—er 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
reOrr\C\a Abn P_
Is applicant the sole legal or equSaDle owner? No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
D-V;s ❑No
Do all joint tenants or tenants in common reside on the property?
If name on record is different than that of applicant,indicate below. ❑‹s ❑No
Name of contract seller Has applicant owned or been buying the property under recorded contract for
at least one(1)year before claimin deduction? Q>�s ❑No
Address of contract seller(number and street,city,state,and ZIP code) t roperty in question:
Real property Iobile home(/C 6-1-1-7)
Keynumber/Legal description Record number Page number
Taxing district( y, \�r �� O'_ 000. y Da- Oa 4,
Does applicant reside on ro 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[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 yea f age more on December 31 the year
$
individual's spouse.)See reverse for details.
Have you filed for any other deductio s? If Yes,what deductions?
Have you filed for deductions in any other nty? If Yes,what county?
❑Yes
I/We certify under penalty of perjury that the6"; )
above
and foregoing information is true and correct.
Signature of applicant Date(month,day,Year l/-9—Address of applicant (number and street,city,state,a code) G �� ����
a a) 5 L:4 c ollft P.c T3ro.r
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
IDate(month,day,year)
Signature of Co —Jt II 1/^ '—
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer