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Age_Smith (9) `o�:=^,r• APPLICATION FOR SENIOR CITIZEN
� COUNTY TOWNSHIP YEAR
��'" PROPERTY TAX BENEFITS
State Form 43708(R15/1-20)
4�+ ,e`Y''/ Prescribed by the Department of Local Government Finance
MIEll
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
Over 65 eduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or co rac uyer) V 1.. S 1 ' I
Is applicant the sole legal r e stable 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 diffe nt t n that Qf applicant,indicate below. Do all joint tehants or tenants in common reside on the property?
❑Yes II No
Name of contract seller Has applicant owned or been buying the property under ecor 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 property in question:
Real property ❑Mobile home.(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
0 Z 26-12 a-i- (-\(A-ono 0- -0 29.
Does applicant reside on p p rty? Assessed value of the property as of current year assessment date(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 agor more on Decemb r 3 f the year
❑Yes o
I/We certify under penalty of perjury tha the above and foregoing information is true and correct.
1 Signatureapplicant , /J Date(month,d ea/9t7/ 2-3
Ad ss f pplicant (numberenn r�ylstate,and ZIP e) /
� � t .`2,-) 1 il '-k r Dn r k --6
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
i
Signature o nrrAuditor� �\� '`n ISCA
D`te t year) )
FP
I)
MAR 2 9 2023
/1u�1ur�( &.,i/11 ,4)
DISTRIBUTION: Original-CountyAuditor; File-Stamped GIBBON COUNTY AUDITOR
gCopy-Taxpayer
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