Age_Tretter APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
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% PROPERTY TAX BENEFITS L R I. State Form 43708(R15/1-20) 3t,s6,0 O 2.V. / Z3
''' Prescribed by the Department of Local Government Finance —
a• 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
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(ow rr�,o-r-•con. act uyer) �
NWT i� •`
Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
❑Yes -
If name on record is different tha t scant,indicate below. Do all joint tenants or tenants in common reside on the property?
❑Yes ❑No
Name of contract settee j Has applicant owned or been buying the property under recorded contract for
Y ^O�y at least one(1)year before claiming deduction? ❑Yes ❑No
Address of contras N.
umber 3 treet,city , ZIP code) Is t e property in question:
O`_` Cl. PJ Real property ❑Mobile home(IC 6-1-1-7)
Taxing district ` "�1key number/Legal description Record number Page number
Does applicant reside on.rop- y0 Assessed value of the property as of current year assessment date rMay not exceed$200,000 for Over 65 Deduction or$199,999
Yes' ❑No [counting just the homestead site)(or the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
le property]for the Over 65 Circuit Breaker Credit initially applied(or after December 31,2019.)See reverse for details.
Is the applicant 65 years of age.r more on December of the year
Yes ❑No l[N� .
Have you filed for deductions i a other ou y? If Yes, hat county?
X. ❑Yes No
I/We certify under penalty of perj th t the above and foregoing information is true and correct. r(7
X '. je re.f applicant I'�'/��%� // - Date(mon ,d rear) J _
•ddress of applica ( umber and siCeet,city,state,and ZIP code)
Signature of au prized presentativ= Date(mo h,day, ear)
fdiess of authorized representative S street,city,state,and ZIP code)
Sign of County Auditor Date(month,day,year)
v� -
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer