Age_Schwartzlose �_R,na APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
7 PROPERTY TAX BENEFITS /� /� 2
5 , State Form 43708(R15/1-20) �t�y� ' 1 _
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 are first due
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Type of benefit requested(Plea the all that apply.) ` `
Over 65 Deduction from Assessed Valuation Ov 5 Circuit Breaker Credit
Name of applicant(owner or conk t Buyer) S C\Atk A t� ' L / C— t
\\\
Is applicant the sole legal or equitable owner? I o,what' his/her exact share'or interest? If owned with(joint tenantl or tenant in common,indicate with whom.
❑Yes ❑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 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 t property in question:
eal property El Mobile home(IC 6-1-1-7)
Taxing district Key n tuber/Legal description Record number Page number
p\ - KL (0-OG-Z6-Ploo -(0ol .8bk(-ol •
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
(counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999(all Indiana real
Yes ❑No property)for the Over
$
individual's spouse.)See reverse for details.
Have you filed for any other dedu ions? If Yes,.what deductions?
Yes ❑No
Have you filed for deductions i a other c un ? If Yes,what county?
❑Yes o
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
VSi ature of p li t 1 1dt� Date(month,day,year)
//t\ Addre1ssq a pt • I` (^J-erS'nL s- k ZIP cod`' — 1 6�O 4
t l J ,\nt t •� Date(month,day,year)
Signature of authorized representative
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of Cgl+Qty Audit r y Date(month,d a
( 1\ 2 Z _
FILED
(26- Oy-2`1-3 -QOO.6 3 s-_ 020)
NOV 2 9 2022
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer ‘t7^/ �Z�Ge (J �
GIBSON COUNTY AUDITOR