Age_Peavler APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
cr.klis PROPERTY TAX BENEFITS
44.1_ •
It.,,,t State Form 43708(R15/1-20)
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*--%"---7.5,---'4' Prescribed by the Department of Local Government Finance 30V) c (1 7
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 eck all that apply.) _
Over 65 Deduction from Assessed Valuation ver 65 Circuit Breaker Credit
Name of applicant(owner or co ract uyet)—..,,,
, \ rN,A0-Alim Te_qu.)\e_A .
Is applicant the sole legal or equitable ovtner? If No,what is his/her exact share or interest? If owned with loint tenant or tenant in common,indicate with whom.
El 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?
E]Yes E1 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?
Ei Yes Ei No
Address of contract seller(number and street,city,state,and ZIP code) I th property in question:
Real property 0 Mobile home(IC 6-1-1-7) •
Taxing district Key number/Legal description Record number Page number
. V)-13- 0,c-IA)D- 000. 10kit,10
Does applicant reside on op rty? Assessed value of the property as of current year assessment date(May Fiot 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 Ei 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 age r more on December 31 of th y r 1
es ON° In On ilT. 3 C\
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Have you filed for deductions n any er c un ? If Yeshal co ty.
0 Yes o
I/We certify under penal of perjury th t the above and foregoing information is true and correct.
igr,ke-of appli nt 4 • Date h,cay,year)
/ 4 '-1/02-.3
ddress o applican ( mber and street,city,state,and ZIP codei) ,.. .{:). .
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Signature of authorized representativ6 Date(month,day year)
Address of authorized representative (number and street,city,state,
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Signal ur o Dun ucclitkjciA
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N- Date(monthty, X 10
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