Age_Cornwell ,07.4 APPLICATION FOR SENIOR CITIZEN
��i:,,�k COUNTY TOWNSHIP YEAR
,,a PROPERTY TAX BENEFITS
rtt��� ,
x'\`'eie I;� State Form 43708(R15/1-20) 1
1 n
6. Prescribed by the Department of Local Government Finance - 300
20,2_,s
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
Type of benefit requested(Please c eck all that apply.)
Over 65 Deduction from Assessed Valuation [Over 65 Circuit Breaker Credit
Name of ap licanl(owner or co act uyer) /\
Is applicant the sole legal or e uit le owner? 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 pll 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 re or d 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 roperty in question:
�ceal property ❑Mobile home(IC 6-1-1-7)
Taxing district �� Keynumber Legal descriptionn 2_0 00 1 53_ (�t A �� Record number Page number
Does applicant reside on p\ p y7 Assessed valueue of the property asas of current year assessment dateat ((May not exceed$200,000 for Over 65 Deduction or 5199,999
Yes ❑No [counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999 fall 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 December 31 of the year
$
Have you filed for any other dX
ns? (f�es1wht deductions?
s No }`jl-Have you filed for deductionsother_ounty? If Yes,what county?
❑Yes ❑No
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signa(urRpplicantXi\
C(1Cf/"� Date(month,day,y ar •
( (-‘41...d--1-4.6— 41-41,4-b0
ddress of applicant number and street,city,state,and ZIP code)210 L5 0 Sfi 1-1 on- 9N �'�� U .
Signature of authorized representative f Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature Clofunn�nA Date(m nthil6rylark,...)VVW` . -
\A - F I LED
fox �� �� (��7
\ �,L \�`� \btu MAR 1 6 2023 �.
.v\ t
A GIBSON COUNTY AUDITOR
ISTFWUTION: Original-County Auditor; File-Stamped Copy-Taxpayer