Age_Ritcheson �� �1 APPLICATION FOR SENIOR CITIZEN / COUNTY TOWNSHIP YEAR
1 .�
0 _ PROPERTY TAX BENEFITS •
w State Form 43708(R16/1-23) (>( p SoN Akzie,o,, 03
'� 's 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 hat apply) ��
Lf8'Over 65 Deduction from Assessed Valuation L?Over 65 Circuit Breaker Credit
Name of Applicant(owner or contract buyer)
If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
Ig Yes ❑ No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
ki-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? IS Yes ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question:
D'‹1 Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
NQZIe-1-or\ "-0 -€9-- 03Q-COO. 330- o f q
Does Applicant Resi 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 Applica 65 Y of Age or More on December 31 of the Year Prior
'es ❑No -lo1v�5 eaA
Have You Filed for Deduction in Any Other County? If Yes,What County?
El Yes
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I/We certify under penalty of perjury at the a ove and foregoing information is true and correct.
Signature of Applicant Date(month,day,year)
9//51a 23
Address of plicant(n mber and street,city,state,and ZIP code)
0\8 w 9- {-(a-z. -"- /A/ Li7Gyo
Signature of Authorized Representative Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of unty Auditor FILE I rj month,day,year)
SEP 1 3 2023
DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer GiBsO CODs\\\
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