Age_Garrett .r.:'r:'2'+. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
',T PROPERTY TAX BENEFITS
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"-' State Form 43708(R15/1-20) /� 30 vl 023
e � , 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
-
Type of benefit requested(Pleasch k all that apply.)
xOver 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of appl' t(owner or con ac uygr)I
on �C)
Is applicant the sole le der eq ble ownn�err
? If No,what is his/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 El No
Address of contract seller(number and street,city,state,and ZIP code) IRReal
roperty in question:
h property ❑Mobile home(/C 6-1-1-7)
Taxing district 23 , Key number/Legal description Record number Page number
26- 12-18-102-000.St2 - 028
Does applicant reside on pr�o{�,erty? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
IQ,J 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
\gproperty)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years of a e or more on December 31 of the year
$
individual's spouse.)See reverse for details.
Have you filed for any other de u ons? If 7.what d-dyctiA ? � f- )ici if
l (c& U
r)
Yes ❑No (, wh `�r�o l' 1►�lt
Have you filed for deductions y other ty?ty? If ,what county? •
❑Yes No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
X Sign re of app
Gre,1 ` 20
/{ //-}� t --nth,day,Year)
l&AfAddress of applicant ( mber and street;city state,,aand d✓yZIP code) ZC_11 �'�2 Z
qo
10 t5 .S nc r St )f'iv'- J-Ai - 4�6 .
Signature of authorized representative / Date(month,day,year)
Address of authorized representative (number and sheet,city,state,and ZIP code)
Signature of County Auditor Date(month,day,year)
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer