Age_Wilson •S APPLICATION FOR SENIOR CITIZEN c UNTY TOWNSHIP YEAR
7� 4 PROPERTY TAX BENEFITS t
a, � i. State Form 43708(R15/1-20) (//��-���Jn �2�o ?�022- -
�'� 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 payable.
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or t acter) t ."�<` isIO�
QIV
Is applicant the sole legal or uitable owner? wh If No,`whatt isthis/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 property in question:
NReal property ❑Mobile home(IC 6-1-1-7)
Taxing district Key_nu^ _ u b r/Legal description
i(b Record number Page number
CD 2- - Li-o —o00 6 -4 z6
Does applicant reside on pe ?
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 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years ag or more on December 1 of the year
$
individual's spouse.)See reverse for details.
Have you filed for any other de coons? If,Yie. at deductipns?
Yes ❑No J
Have you filed for deductions i y other co ? If Yes,what county?
❑Yes
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
X STri of ap 1{t icant a� (re• t o`/� Date(month,day,I Ll I LI [1'0
Z- -
Addr q(applili�/rant�(,1 ^^lumber1t;\;t,cc l/ hate,and Vode) 1i� 1) 31 / __ L\ 6Lig
Sig ature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,( iIIIII)
sttaand ZIP code)
Signature of County Auditorfyluo Date( ( nth)di ,ea) ,
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer