Age_Burger ""' APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
7 , PROPERTY TAX BENEFITS ,
+, • / State Form 43708(R16/1-23) \\� tt II 03
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\f '•�!% 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 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)
— Over 65 D-• • -_,1;.A ed Valuation ✓Over 65 Circuit Breaker Credit 1
Name of Applicant(o,vne,c•contract buyer) ". {
If Owned with Joint Tenant or Tenant in Common,Indicate with Whom I
Yes No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property'?
—✓ es P 7 No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
�� i
One(1)Year before Claiming Deduction? •+-QS _ No
i----
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 I Legal Description Record Number Page Number
v �`COIN (IV - M-09- 3cD-000- 0911 - O 5
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
? FILED
Er-Yes ❑No I-1 0n2e5
Have You Filed for Deduction in Any Other County? If Yes,What County?
❑Yes Elio JAN 02 2024
` /
I/We certify under penalty of perjury that the above and foregoing information is true and correct. ,
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Address of Applicant(number and street,city.sta and ZIP code)
CO So0k� 11 5 ' f 4_• 13C�� �Ilf �7 6 qgateSignature of Authorized Representative (month.day,year)
E. Address of Authorized Representative(number and street.city,state.and ZIP code)
i Signature of County Auditor Date(month,day.year)
n \j/ �� 1 a- 9 --a3
DISTRIBUTION: Original—County Auditor: File-Stamped Copy—Taxpayer