Age_Lear ,,,.,Rmt,• APPLICATION FOR SENIOR CITIZEN COUNTY
UNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS r/7 � '/1
tl. State Form 43708(R15/1-20) 0 2(� f ( 2(___
�`. - e' 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
■Ove - Deduction from Assessed Valuation ❑Over 65 Circuit Breaker Credit
Name of apple-, (o = •r contract buyer)
^
\/'a .
Is applicant the s• -. - - -• - • - 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 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 unde d contract for
at least one(1)year before claiming deduction? es ❑No
Address of contract seller(number and street,city,state,and ZIP code) I t property in question:
Real property ❑Mobile home(IC 6-1-1-7)
Taxing district
Key number/Legal description Record number Page number
2- . 26- G-tq-1 oi-0o0�LI6- �c
Does applicant reside on rty? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
'o��oot,Q counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,and$l99,999(all Indiana real
Ia1 Yes ❑NO pe ]for the
$
individual's spouse.)See reverse for details.
Have you filed for any other dxes
tions? If Ye hat deductions? \�j' 1 1l1
Y ❑NoS�C(�.dl 'i' y�rl-NI",,• 1 _
Have you filed for deductionsY othe ou If Y ,what county?
❑Yes No
I/We certify under penalty of perjury t t the above and foregoing information is true and correct.
pplicant Date(month,day,year)
Signatur, 0���0� `
� ...
=r-lir�C�
A sts of applicant (number and�c\et,city_state,and,ZIP�� �/ q .
1, tWepresent .-'(w -J Date(month,day,year)
ignature of authorized representative
Address of authorized representative (number and street,city,state,and ZIP code) t1tl
ate( ofI .Signature of County Auditor0
NOV 2 2 2022
°792,, a
GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer