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) 0-,t 2.o I Q-a-c . 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 4,c ,,_x.a (\ - ALL:: ►�` A 1 10—Q-a:- _ C c .aJ,�/a�o a . DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer ' ' SON COUNTY aJ GIBSON COUNTY AUDITOR