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APPLICATION FOR SENIOR CITIZEN Cr NTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
5 t 4.:Li State Form 43708(R15/1-20)
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Prescribed by the Department of Local Government Finance
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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 payable.
See reverse side for additional instructions and qualifications.
Type of benefit requested(Please check a apply.)
Over 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Name of applicant(owner of contranuyer)
tDe.bra LI Vex'371e. _,
I applicant the sole legal or equita vner? If No, i at is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
es 0 No
i If name on record is different than that of applicant,indicate below, i Do all joint tenants or tenants in common reside on th bperty?
Yes ID 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?
El Yes Pig-a Address of contract seller(number and street,city,state,and ZIP code) Is the p,peity in question:
Real property 0 Mobile home(IC 6-1-1-7)
Taxinrt&ii' t . /1 Key number/Legal description Record number Page number
01_ 0,6, 55c - oz2_....
Does applicant reside on propf.5,y7 Assessed value of the property as of current year assessment date(Mar 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
111 Yes 0 No property]for the Over
54 6/14 / ‘-7/
Have you Filed for deductions in any other county? es,what county?
0 Yes o
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
tnature pplicant Date(month,day,year)
, V-sail--Q-ilk
Address of applicant (nu er and street,city,state,and ZIP code)ra
- 24-13-,10 23
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Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
SignatureCountZito2 4. . -fizi/L/01,4 Date(month day,ye r)
FILED
APR 1 3 2023
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GIBSON COUNTY AUDITOR