Age_Copley ,—.F4 .c.. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
7 i • �Y PROPERTY TAX BENEFITS
, "� State Form 43708(R16/1-23) 1
::: a,n oZg 7.023
!ar!% 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
Type of Benefit Requested(Please check all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Namant weer or contr c er) Telephone Number ail Address
`K ,V A P ( '
Is Applicant the ole Legal r Equitable O 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 Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
Ei 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? nes ❑ No
Address of Contract Seller(number and street,city.state,and ZIP code) Is the Property in Quest' n:
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
O 2•S • 2{3-Ai-08-2o3-001-Z.5T-OZ2
Does Applicant a ide 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 E No Indiana real property]for the Over 65 Circuit Breaker Credi initially applied for after December 31,2019.)See reverse for details.
Is the Applicant 65 ear of Age or More on Decemb r 3 of the Year Prior
—
Have You Filed for Any ter Deductions? If Yes,What Dedluc ions,?
Yes El No tit
S + v S .
Have You Filed for De u ion in Any Other County?p(No
If Yes,What County?
❑Yes
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Sig of Applicant ,00Date(month, ay,year
,4,ei76...fr .-ex
, .
Addr A li t num er and s r t city.st .and ZIP code)
PP ( ��
Signature of Authorized Representative Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of Couruy Audito FTLT,D Date(mdnlh,day, ear) .
i 101[1.4, tr2 2T '1z3
DEC 2 7 202
DISTRIBUTION: Original—County Auditor; File-Stamped Copy— ayeer a /
GIBSON COUNTY AUDITO