Age_Gaston :..f'-"'� APPLICATION FOR SENIOR CITIZEN f—
�3 { COUNTY TOWNSHIP YEAR
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PROPERTY TAX BENEFITS
State Form 43the (R16 t 1-23; i CO O2-
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!.• Prescribed by the Department of L,cal Geiernmen:F na-ce
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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 check aIi that apply)
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I Over 65
If Owned with Joint Tenant or Tenant in Common.Indicate withWhom ,
-._ 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?
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_- Yes ' No
Name of Contract Seller I Has Applicant Owned or Bougrt the Property U der Recorded Contract for at Least
One(1 i Year before Claiming Deduction? Yes _ No
Address or Contract Seller(number and street city state and ZIP code Is the Property in Que ion
--XReal Property _ Mobile Home(IC 6-1.1-7)
Taxing District2.8 Key Number;Legal Description Record Number Page Number
n 2)- [1-01 --.--a ‘l -00 0 i q) Z---(9
Does Appl cant Reside on Property? Assessed value of the property as of current year assessment date(May not exceed S240.000 fcr Over 65 Deduction or
S199.999(counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1.2020. and S199.999(a%
Yes _ No Indiana real property]for the
I.I Yes ❑No
Have YOU Fled for it:d• lion in Any Other C n i If Y s What County
i
■ Yes o
CA-‘-V1--
INV'e certify under penalty of perjury that th above and foregoing information is true and correct. e�o'L4
S: ur gnaie of Apr•
ant j Date(ri 9 d�y.year)
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rie
Address /(Appl' 1 um era e . c:y state. d ccde! -- - Qi•~� ;
-3-214 rr-s -\-- r rdn- 30 - 1,--\ 7-4)--b.
Signature or Authorized Representative )
Daf9ti!fon0
tn day,year)
Address of Authorized Representative(number and street.city.state and ZIP code:
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S 5 ,. .c -- - -- - Date(mcn . day yea • - --
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DISTRIBUTION: Original-County Auditor. File-Stamped Copy-Taxpayer