Age_Utley 7:<� APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
-= • •. PROPERTY TAX BENEFITS -
x' ' 31, State Form 43708(R15/1-20)
MO
J� 02,g. 2-3.- Prescribed by the Department of Local Government Finance
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
G1 Over 65 Deduction from Assess-: ealuation Over 65 Circuit Breaker Credit
Name of applicant(owner or co tact wyer)
r^I
n / -2 ►0
Is applicant the sole legal or equitable owner? If No,what is nis t:er exact share or interest. If owned with joint tenant or tenant in ommon,indicate with whom.
El Yes El No
I If name on record is different than that of applicant,indicate below. I Do all joint tenants or tenants in common resi o he prbperty?
es ❑No
Name of contract seller Has applicant owned or been buying the property and re r d contract for
at least one(1)year before claiming deduction? es ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is e property in question:
eal property LI Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
Does applicant reside on property? Assessed value of the property as of current year assessment date(May nof exceed S200,000 for Over 65 Deduction or$199,999 1
['Yes El 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
es ❑No 3 ` IW`jQ �Have you filed for deductions' an oth r county? If Yes, at co V J
❑Yes
I/We certify under penalty of perjury th t the above and for oing information is true and correct.
ASig � ap ' nt 6_ Da th,da ,yea_ r)
Ad ss of apAltcant (number and street,city,state,aZ./ code)
Signature of authorized representative / Date(month,day,year)
Address of authorized representative (number and street,ci , and ZIP code)
Signature of County urb7 sl- Date(moil d ei I4ED
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MAY 0 3 2023
GIBSO'N COU NT ij
AUDITOR