Age_Johnson 0,3rtq.•
APPLICATION FOR SENIOR CITIZEN C?UNTY TOWNSHIP YEAR
`- • PROPERTY TAX BENEFITS
11
514.1i). State Form 43708(R15/1-20) 0�V 23
Prescribed by the Department of Local Government FinanceTS0 f(1
leis
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 he k all that apply,) �.
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
'Name of applicant(owner or co roc buyer!
S OVMS Oil
Is applicant the sole legal or equitable oviner? If No,what is his/her exact share or interest? If owned with Lint tenant or tenant in common,indicate with whom.
❑Yes ❑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 rec ed contract for
at least one(1)year before claiming deduction? Yes ❑No
Address of contract seller(number and street,city,state,and ZIP code) I the roperty in question:
Real property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number!Legal description Record number Page number
0 2S '
Does applicant reside on p p ? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
Yes ❑No (counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
I property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years f a or more on Decem er 1 of the year
$
Have you filed for any other de u ions? If Yes,what deducti ns? `_ (3).
Yes ❑Nov `ce� (Dvs 0911\ '�/1 �r\G)
Have you filed for deductions i a y other ty. If Yes,what county? J III
❑Yes No V
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
C1Ta.,.-
,9.z ture`bf applicant 7 � �_ n x ` 1 onth,day,year)
0 r11+U1 II I� � Z3
Address of applicant (number nd street,city,state,and ZIP code)
c\I— S eStAA V `---1-on- Dfv- \.\ 69°. - -\,\..)
Ar
4It
Signature of authorized representativea
% Date(month,day,year) (\
Address of authorized representative (number and street,city,state,and ZIP code
Ikte,(2.ii.04",e,
.00
PSi nature of CountyAudi r % I GON_\` Date(zit t, a e•' 2_,.
*
I
-
r -