Age_Blackard 4'�'t •,,, APPLICATION FOR SENIOR CITIZEN
COUNTY TOWNSHIP YEAR
l._ . _ =i PROPERTY TAX BENEFITS `
�' Slate Form 43708(R15/1-20) ` /]�
'+ If Prescribed by the Department of Local Government Finance J \ CD 2�� Ir` 2.
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File Mark
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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
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Type of benefit requested(Please h ck all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
' Name of appli t(owner or co trac uy
� nni P r\o_ QC " "a •
Is applicant the sole legal or equite le miner? If No,what is his/her exact share or interest? If owned with Joint tenant or tenant in common,indicate with whom.
ill Yes El 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?
❑Yes ❑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?
❑Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) Is property in question:
Real property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
02� 26-kg-o9 -- 30o—ool • 1‘‘ — b2S- ,
Does applicant reside on p er)y? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
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 the
?
Yes ❑No
Have you filed for deductions n an other y? If Yes, hat county'?
❑Yes ouNo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Date(m th ¢ay,y �j _ 2
A re of applicant (number and street,city,state,and ZIP code) C//
1 Ci E60o c F1 "-- 'w.,,Ad.t1 - 3n •
Signature of authorized representative Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Signature of Coy Auditor Date(mo ,year
.t`,-(,1 (,�,J�,1 FILED 2-
JUN 0 2 2023 `
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GIBSON COUNTY AUDITOR