Age_Carroll i
APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
k PROPERTY TAX BENEFITS
�x. State Form 43708(R15/1-20) '��t C Z`^ 025 —� ��
'' Prescribed by the Department of Local Government Finance v 1 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
Type of benefit requested(Plea .c -ck all that apply)
'%4JI •ver • r.-duction from Assessed Valuation Over 65 Circuit Breaker Credit
Name o plicant(ow:er�.r r y0er)n^� / -3\\ '
Is appli t the sole legal o •.uitable owner? 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 ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is a operty in question
eal property ❑Mobile home(IC 6-1-1-7)
Taxing district 0
2
May not exceed$200,000 for Over 65 Deduction or$199,999
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
property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years of g r more on Dece be 31 of the year �Ap licant's date of birth(month,day,};ear) If filed b a surviving,unmarried spouse,what was
prior to the year taxes are rst d and payable. 2f _\7__t�"l,_`O\�o� ,S, th o e's age at the time of death?
Yes ❑No lib v
Adjusted Gross Income(AGI)of applicant,ap is nt and spouse,or applicant
$
individual's spouse.)See reverse for details. ��v� �.�
Have you filed for any other dXy
ions? If Ye ha[de ns? �, \� V .
Yes ❑No S Have you filed for deductions other c u ? If Yes, hat co nty?
❑Yes o
I/We certify under penalty of perj ry tha the above and foregoing information is true and correct.
V Si9Aa}ure of applica t n n Date(m nth,day,y ar)
I/\\4 tly(2,-&-,_. 1A.uA-t�J� '2 Rim��
dress-_s of ap i a t (number and street,city,state,and ZIP code)
y\ W r-RA--C'*-Xe- .
Signature of authorpresentative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Sigrq f C ty i or DateV( c ar)
Y` t/I1
FILED
JAN 2 0 Z023
GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer