Age_Taylor tt�er APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
11..`-\a PROPERTY TAX BENEFITS
i1+ Stale Form 43708(R15/1-20) CoOkU r`t-bi Qt
•� f Prescribed by the Department of Local Government Finance Lic1.501, 7....
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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 payable.
See reverse side for additional instructions and qualifications.
Type of benefit requested(Please check all that apply.)
t_y'Uvka�er 65 Deduction from Assessed Valuation ae ver 65 Circuit Breaker Credit
Name of applicant owner or contract buyer)
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Is applicant the sole
ellegal or equitableIf No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
V
If name on record is different than that of applicant,indicate ibelow. Do all joint tenants or tenants in cpmmon reside on a 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 the pr erty in question:
eat property ❑Mobile home(IC 6-1-1-7)
Taxing district Key num er/Legal description Record number Page number
�mb\ a__ . a k- I14— 1q ._ 300 — Ooo.9 1491—O .
Does applicarlt reside on property? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
I r—✓ ❑No [counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
L1 es property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applica it 65 years of age or more on December 31 of the year
$ -
Have you filed for any other deduction ? If Yes,what deductions?
rUP6s ❑No Qd
Have you filed for deductions in any other county?coy If Yes,what county?
['YesLII
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Date( -
Address of applicant (number and street,city,sute,and�h code)
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Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of County Auditor Dale(month,day,year)
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