Age_Montz "` „'s.. APPLICATION FOR SENIOR CITIZEN r COUNTY f TOWNSHIP r YEAR
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1 PROPERTY TAX BENEFITS r (/-- - j
(•�; .,� State Form 43708(R16/1-23) i V lb Son p a3
.•i!%' Prescribed by the Department of Local Government Finance To��S~�9
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 flied 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)
C^ver 65 Deduction from Assessed Valuation ter 65 Circuit Breaker Credit
Name of Applicant(owner or contract buyer)
Owned with Joint Tenant or Tenant in Common,Indicate with Whom 1
�! Yes — No
If Name on Record is D.fferent than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
.ems . No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least ,
One(1)Year before Claiming Deduction?
s '� No
Address of Contract Seller(number and street.city.state,and ZIP code) Is the Property in Question'
�eal Property LT Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
Qc.-.4-0- to 5),,:e 2 G-1(-lag" IOO- DOD. it37 - 0a-
Does Appfca R. de 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
Yes ❑No "bt5c%\::‘Vs rvteSfeChZI
Have You Filed for Deduction in Any Other County!!? Y ��
❑Yes l�No \i)vo y !J J( v\ �\����"
1
I/We certify under penalty of perjury that the above and foregoing information is true an rect. \�
Signature of Appli i lilt.nt b�l Dat month,day,year)_,
!( i v YL i 8 1 6,
� Address of Applicant(number and street,city,state.and ZIP code)
q a NJ Shy Ly\ ?r\\ALe-kov\ T I') 1'V-7 c.7 0
Signature of Authorized Representative 1 Date(month,day,year)
I
Address of Authorized Representative(number and street,city.state,and ZIP code)
Signature of County Auditor FILEDDate(month,day.year)
DEC 0 8 2023
Ilu./.1 a.LI/d,6irn4J
DISTRIBUTION: Original-County Auditor; QIt$8t0iM(fegWY 49j7>Sf"