Age_Hyatt '`"`'' APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
0 1,1 PROPERTY TAX BENEFITS
4;2/9 State Form 43708(R16/1-23) (, 1 SO/1 O ~ISv 1\' o73
\=•• 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)
2<ver 65
If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
rkire-S E No
If Name on Record is Different than Applicant,Indica I L E D Do All Joint Tenants or Tenants in Common Reside on the Property?
Q.-Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
A U G 0 8 20 One(1)Year before Claiming Deduction? ❑1es ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question:
0 Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Kelritgrtgy r Record Number Page Number
(�..)ems .\�
t7�-i1-I _UBla8R Ila - oaa
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
❑ Yes ❑ No Indiana real property]for
p'�s ❑No .\;�A t KOe5
Have You Filed for Deduction in Any Other County? If Yes,What County?
❑Yes 1;14o
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature o plicant Date(mon h,day,year)
Address of Applican enum1 r aid street,city,state,and ZIP code)
9ff7 S / 'k - 5i- bt,,e .sN.Ve. 1 , N7665
Signature of Authorized Representative Date(month,day,year)
PI)I-- i✓�6m.` -G fa-
Address of Authorized Represents a(number and street,city,s ate,and ZIP code)
Signature of
Cuntyy Auditor Date(month,day,year)
, 40 61/4,43L /r.
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer