Age_Seibert s"`"`" APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
l `�1 PROPERTY TAX BENEFITS
SI,616),
State Form 43708(R16/1-23) vw.Dvxg 3
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)
L�"Over 65 Deduction from Assessed Valuation i 'Over 65 Circuit Breaker Credit
Name of Applicant(owner or contract buyer)
with Joint Tenant or Tenant in Common,Indicate with Whom
C`/es E No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
❑es ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
One(1)Year before Claiming Deduction? 17 yes ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question:
❑ I-eat Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
26-l9--11-1.-00 -OC2- 0 j - OZ r-
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
121 Yes ❑ No Indiana real property]for the
:,
Have You Filed for Any Other Deductions? If Yes,What Deductions?
[Wes El No 4-ID/h�7-1-1
Have You Filed for Deduction in Any Other County? If Yes,What County? AUG 5 2023
❑Yeso l7
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
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Signature of 'cant - Date(montth doN ay, Al�F Y AUDITOR
_.-t-e...- ..S.1026.12)--e—j— ki cA/ /5 , (3 z,,.
Address of Applicant(number and street,city,state,and ZIP code)
��3Y s aoo t F A -3 c-c,„cl, -a ,/ `r)414 S
Signature of Authorized Representative Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of County Auditor Date(month,day,year)
iv . ,,Al� PV g//s/a 3
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer *.\(117---'0