Age_Beck (2) ��`-n,r°� APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
telt PROPERTY TAX BENEFITS I
; ;1 State Form 43708(R16/1-23) GO 0 1. 23
L`�� Prescnbed by the Department of Local Government Finance , ,_,0 ,,,
\JInformation 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 l/that apply)
Over 65 Deduction from Assessed Valuation ii/Over 65 Circuit Breaker Credit
Na e of Applicant wner or contr t uyer) Bail Address
Is Appli a t e Legal or Equitable Owner'? If No.What is His/Her Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
Yes ❑ No
If Name on Recor 's Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
I ❑ 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? U Yes ❑ No
Address of Contract Seller(number and street.city,state,and ZIP code) Is the Property in Question:
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description '' \\ Record Number Page Number
r�
0 C 2t-11_l— Ict - )ou - coo. 0 s-Z -- op
Does Applicant Rest 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
es ❑ No Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the Applicant 65 ar of Age or More on December 31 f the Year Prior
Have You Filed for Any er Deductions? If Yes, hat Deductions'? LE
esI)Have You Filed for Dgductio in Any Other If Yes, hatt County? 0�
❑Yes No
/
2020,
I/We certify under penalty of perjury at th above and foregoing information is true and correct.
Signature of)kp licant �D�l/ year)
P��Caggd 4cK ' � '� ;
Address of Applican (nu ber an street,city state,and ZIP code) OfrOR ✓
t 31--- S «oOE , o' a G j—.-Ds° — 1—C+66 0
Signature of Authorized Representative Date(month,day.year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of County AuditoMr ( � ��''�y Date(month, ay, ar)
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9Fc,C.
DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer De; `,!i ,,.
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