Age_Petitjean •''' APPLICATION FOR SENIOR CITIZEN
E i' -' PROPERTY TAX BENEFITS COUNTY TOWNSHIP YEAR
Si. . -3708(R1 23) f ,„Nn 0 2 J ..yp n
''• Prescnceo 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 the county auditor or postmarked by the following
January 5 of the calendar year in which the properly taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Type of Benefit Requested(Please check all that apply)
65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
,_.,e:If Apetca_1 ro:vre-:'c ^!raROver
yer
c al Address
Is Ai:. '-e Sole Legal c' :.table Owner? If No.What is His/Her Exact Share or i--,-est? If Owned with Joint Tenant or Tenant in Common.Indicate with Whom
_ Yes _ No
If Na-re on Record is D fferent than Applicant,Indicate Belot. Do All Joint Tenants or Tenants in Common Reside on the Property?
-- — Yes ] No
Name of Cont-act Seller I Has Applicant Oared or Bought the Property Under Recorded Contract for at Least '
One(1)Year before Claiming Deduction? _ Yes _ No
Address or Contract Seller(number and street city. state and ZIP code' Is the Property in Question
eal Property _ Mobile Home(IC 6-1.1-7)
Taxing District Key Number;Legal Description
O �� Record Number Page Number
• Z6-23-)y-3oo_ 000.7-7 g--O2-� .
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 1.202G and$199.999[a+
Yes _ No Indiana real property/for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the Appl:ca 6 Year of Age or More on December 3 f the Year Prior =
Have YCJ Filed for Any Other Deductions? If Y ihAI Deductions% l
____ tij`JL
As ❑No '
Have Ycu Fled for ducti in Any Other County? ' If Yea.What County?
❑Yes �No
/ \ Y01 ?
IMIe certify under penalty of perjury that the above and foregoing information is true and correct.G43, �2�
S,tnature of Applicant /���
N o
4I �,� - r Da. vTy y ail
• �0 R
OfTO
—
`�•ddress of Applicant(num r and street city st and ZIP code,
12- 6nR s 3 Sc) E '\1 vJv0 — Dil4 - - 63 c
•
Signature of Authorized Representative 'Date rr;ontn day.year)
Address of Authorized Representative(number and street.city.state and ZIP code
\Ont( f3.1) 'Date Im th. y year;
S 1 � ZL1 •
DISTRIBUTION: Original -County Auditor, File-Stamped Copy-Taxpayer