Age_Belcher APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
a� PROPERTY TAX BENEFITS 1 ��
� i2 State Form 43708(R15/1-20) �
-,s_� '' Prescribed by the Department of Local Government Finance \`_
�J\ 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
Type of benefit requested(Pleasyvck all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or conuyer)
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 El 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. ❑Yes ❑No
Name of contract seller Has applicant owned or been buying the property under re 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 property in question:
Real property ❑Mobile home(IC 6-1-1-7)
Key nu er/Legal description Record number Page number
Taxing district 022 C ` ? 0 I 0 2—
L 1 0�-�—t�
Does applicant reside on p perty? Assessed value of the property as of current year�ss�ssment date(May not exceed$200,000 for Over 65 Deduction or$199,999
ro,.{ (counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999(all Indiana real
�J Yes ❑No property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years f a e or more on Decem d1 of the year
single return;or(2)$40,000 for individuals who filed a joint return with the TOTAL $
individual's spouse.)See reverse for details.
Have you filed for any other de ions? If Yes,frha deductions?
Yes ❑No l}}1 J
Have you filed for deductions i a ther county? If Yes,what unty?
❑Yes ❑No
I/We certify un er penalty erjury that the above and foregoing information is true and correct.
Date(rlrgnth, aea K4S))
Signatur o plicant \l1
7
gdd-_7 ss applica (number and treat ity,state,and ZIP code)
l I Date(month,day,year)
Signature of authorized representative
Address of authorized representative (number and street,city,state,and ZIP code)
I Date'(mo thl days y a ^
Signature of Co my dit . Cs--- ...)
1` L \o/ 1Y\�-/�\ w `t
FILED
NO V 2 8 2022
GiesoN
O ,
DISTRIBUTION: Original-CountyAuditor; File-Stamped Copy-Taxp y r UNTy
