Age_Davis (6) --""_4 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
44 1,1 PROPERTY TAX BENEFITS
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`/ State Form 43708(R16/1-23) Cat D�n �c 11nC€f on d 3
!co. 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)
LTOver 65 Deduction from Assessed Valuation L7 Over 65 Circuit Breaker Credit
Name of Applicant(owner or contract buyer)
Is Applicant the Sole Legal or Equitable Owner? If No,What is His/Her Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
lI Yes ❑ No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
2 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? g'Yes ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question:
I?Pr eal Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
?f►lIC€ fon 0G-0-08- PS- DOD_SGy- O
Does Applicant Reside 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
L7 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 65 Year of Age or More on December 31 of the Year Prior
Have You Filed for Any- er
Other Deductions? If Yes,What Deductio . �
Yes ❑NO t-I WnS\- / ` t S 0.b ,�01 V h O'1 Ate
Have You Filed for Deduction in Any Other County? If Yes,What County I r p
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Dyes ❑No Z
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applica Date(month,day,year) I a
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Address of Applicant(number and street,city,state,and ZIP code)
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Signature of Authorized Representative Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signaturef County Audit FILED Date(month,day,year) 4
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JUL 2 8 2023 \\
DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Ta N D OR