Age_Sands t,,^•�, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
,. = PROPERTY TAX BENEFITS
a'\ State Form 43708(R15/1-20)
%�, 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 all that apply)
r 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
RO.AC(05A r P~e 50nt
Is applicant the sole legal or equlta le 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
1 If name on record is different than that of applicant,indicate below. I Do all joint tenants or tenants in common reside on the prbperty?
es ❑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? Cil- es ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is,-tt-h,ee�property in question:
L�Keal property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
Cent e aC2-13—?' — 100—c x . y59— cry
Does applicant 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
[counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
❑Yes ❑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
DGS El No (-(OV1n eS f ed.
Have you filed for deductions in any other county? If Yes,what county?
❑Yes
I/We certify and enalty of perjury that the above end foregoing information is true and correct.
Signature o pplicent Date(month,day,ye r)
�� Di -o7S- 23
Address of applicant (number at,city,state,and ZIP code)
Y
COOT E 015•O 5 Fro.-^c:sccs L ' 't?441
Signat/ut�'of authori ed rep entative Date(month,day,year)
c c-----(7.1.4/2.,'
rdss Add of authorized representative (number and street,city,state,and ZIP code)
J 1j 1I..I'EE1 Ii
Signature of County Auditor �C� � Date(month,day,year)
e--''/,// APR 2 5 2023
7 a.1ri4)
GIBSON COUNTY AUDITOR