Age_Montgomery (2) �"="-=� APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
47115 PROPERTY TAX BENEFITS
. � State Form 43708(R161 1-23) �{ S�Y) 2 '
' '• 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 c ec all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of Applicant(owner or contr t uyer)
If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
❑ Yes ❑ No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
❑ 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? ❑ Yes ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the P perty in Question:
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
021 6-11- 12-‘00-000.a02-02-1
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 the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the Applican 6 Year of Age or More on December 3 of the Year Prior
$
Have You Filed for An Ot r Deductions? If Yes,What Deduction
►.l Yes ❑No 1#,--1,t S tLPC7\`
Have You Filed for I-du•ion in Any Other Coun ? If Yes,What County?
❑Yes No
I/We certify under penalty of perjury that t e above and foregoing information is true and correct.
tun of•:.;A n Date(month,day,year)
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A dress of Appli ant(num d t street,city,stnd ZIP code) / _
-7 V
Signature of Authorized Representative/ Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)Signature of County Auditor Vat nth,ED
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DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer ' ' SON COUNTY aJ
GIBSON COUNTY AUDITOR