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Age_Lewis .01 APPLICATION FOR SENIOR CITIZEN 2.-\A PROPERTY TAX BENEFITS cc�uNTY TOWNSHIP YEAR Nioft State Form 43708(R15/1-20) , J Q,^ s \ C 24 (1CO 22 —4 a%'•' Prescribed by the Department of Local Government Finance r File Mark Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. tIO INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located. 6P.l DO C� I - 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. Name of applicant(owner or contract buyer) 0.rrcz . L-e___3.,3 i-S, Is applicant the sole legal ore itable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom. es ❑No - If name on record is different than that of applicant,indicate below. I Do all joint tenants or tenants in common relside on the property? es ❑No Name of contract seller Has applicant owned or been buying the property under recorded contract for 1 at least one(1)year before claiming deduction? s II]No e Address of contract seller(number and street,city,state,and ZIP code) Is the property in question: [)-Zeal property ['Mobile home(IC 6-1-1-7) Taxing district Key number/Legal description Record number Page number -()rr h c�-4-avn aLsz - \Q - E — 1 O - r) ( ,I: ,`l-0 Does applicant reside on propel ? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999 [counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real (�1 es ❑No 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 age or more on December 31 of the year $ Have you filed for any other deduction If Yes,nat deductions? es ❑No ` A .1 Have you filed for deductions in any other county? If Yes,what county? • _. ❑Yes ❑No I/We certify under penalty of perjury that the above and foregoing information is true and correct. Signature of applicant Date(month,day,year) ddress of appli.ant (n mber and street,city,state,and ZiP code) Signature of authorized representative Date(month,day,year) Address of authorized representative (number and street,city,state,and ZiP code) Signature of County Auditor Date(month,day,year) --1.\(-A\_/ .._1—\CIS----k (---t. • 3--A—\a . AD) in"(- 1S1-4--) L—ft— U—D,' FILED APR 0 6 2023 ,,t.:?7 sck- '1;?,.,.1f.a_z_1 a J�Ywk 41) GIBBON COUNTY AUDITOR DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer