Age_Loomis t,, • APPLICATION FOR SENIOR CITIZEN
COUNTY TOWNSHIP YEAR
4/' , PROPERTY TAX BENEFITS
x;.�� _��I State Form 43708(R15/1-20)
' • Prescribed by the Department of Local Government Finance Qp(� a o.
leis — c/1 1
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 hat apply)
. Over 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Na`Ca of applicant(owner or contract buyer)
—'% ,s
Is applicant the sole legal or equitable ov ner? If No,what is his/her exact share or interest? If owned with int 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 reside on the prbperty?
IX.; ❑No
Name of contract seller Has applicant owned or been buying the property under recordeSspntract for
at least one(1)year before claiming deduction? PP es ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is the propertypr in question:
&10 al property ['Mobile home(/C 6-1-1-7)
Taxi g district Key number/Legal description Record number Page number
� ate- 1a-11- 1 ors • COO . 3gP- VA.
Does applicant reside on propert Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
es ❑No (counting just the homestead site]for the Over 6i5 Circuit Breaker Credit received before January 1,2020,and 5199,999(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 of age or more on December 3 f the year
es ❑No IS . MdY 09
Have you filed for deductions in any other county? If Yes,what county? /7 �0��
❑Yes ❑No
I/We certify under penalty of perjury that the above and foregoing information is true and correct. G/g�VN C UN y'
AL/ ro
Sig lure of applicant 2 Date month y,year R
Address of applicant (number and street,city,state,and jJp code)
3 O '
Signature of authorized representative t Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Sign re of County Auditor Dateonthay,yead