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Age_Fuhrman 9"'! APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR `',1 PROPERTY TAX BENEFITS ".- . . State Form 43708(R16/1-23) G l v)50-1 l f mce fof a 3 .1,....../ Prescribed by the Department of Local Government Finance 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 all that apply) Cii'eTver 65 Deduction from Assessed Valuation ❑'fSer 65 Circuit Breaker Credit Name of Applicant(owner or contract buyer) If Owned with Joint Tenant or Tenant in Common,Indicate with Whom [ "</es ❑ No If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property? P-Yes ❑ No Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least One(1)Year before Claiming Deduction? L Ves ❑ No Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question: Real Property ❑ Mobile Home(IC 6-1.1-7) Taxing District Key Number/Legal Description Record Number Page Number r\AC,,(2, h 214— —O7— lot-oob. Ikq-©aS Does Applicant side on Property? Assessed value of the property as of current year assessment date(May not exceed$240,000 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$199,999(al Yes ❑ No Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details. Is the Applicant 5 ar of Age or More on December 31 of the Year Prior t3 rr Yes El kkp�1i`g6kNo�+ • Have You Filed for Deduction in Any Other County? If Yes,What County? ❑Yes Eil No I/We certify under penalty of perjury that the a ove and foregoing information is true and correct. 1 Sign`at re o Applicant' A - Date mont ,day„year,f e'. .-1-e=e4--" f -0 kiy -E-Aat .. : ii-c-Lyvit.a.x.,...... -T Address of Applicant(number and street,city,slat ,and ZIP code) 1� SAS lit) ©a� ?e„n ton �/ ,-1)6 7 O Signature of Authorized Representative Date(month,day,year) JUL 13 2023 Address of Authorized Representative(number and street,city,state,and ZIP code) �, /'/2zCl'u/i (2,.. .!/fry`]. :.ncb) Signature of_ / County Auditor GIB 5�$,4 bC9RlIN�a4Y�A(1J�7'ITOR M DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer a