Age_Smith FITi Th. APPLICATION FOR SENIOR CITIZEN "- -- -
y PROPERTY TAX BENEFITS COUNTY IP YEAR ,
C Stale Form 437G l 1-2.3; C e 1 w/f� �^(�
tsi. Prescribed ISOv�'AY T i L4L�1 fN L•�
P z� e=by the Department of Local Gcve^nment F na-.c=_ lJ
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. a
INSTRUCTIONS: To be filed in person or by mail with the county auditor of the county where the property is COUNTY AUDITOR
ocated
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(Plea chec aN that apply)
Over 65 Deduction from Assessed Valuation _ Over 65 Circuit Breaker Credit
1.-----
Name c'Applicant(owner or contra t b' er;
If Owned with Joint Tenant or Tenant in Common.Indicate with Whom
s _ No
•
If Name on Record is D fferent than Applicant.Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
1.
_____ _ Y• es _� N• o
Name of Cortract Seller Has Applicant Owned or Bougrt the Property Under Recorded Contract for at Least
One(1)Year before Claiming Deduction? _ Y• es _' N• o
Address of Contract Seller(number and street city.state and ZIP code Is the Property in Question-
dal Property _ Mobile Home(IC 6-1.1-7)
rig District TpI Key Number I Legal Description Record Number Page Number
�lv_od - 58 • ayq _ 000. g83 �a18
Does Appl cant Res:de on Property? Assessed value of the property as of current year assessment date(May not exceed S240.000 for Over 65 Deduction or
� S199.999(counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1.2026 and S199.999 fa!✓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 Applicart 65 Year of Age or More on December 31 of the Year Prior
Have You Filed for Any Other educt;ons? i If Yes.What Dedu ns?
Yes ❑No i-i $ _ Tv, ,7 , zu, ezJ�Have You Fled for Deduction in Any Other County? If Yes.What Cou - -
❑Yes o
INVe certify under penalty of perjury that the above an foregoing information is true and correct.
r _
: zP ::::lnJrn9andsteet
antr�ay.year)
cty to .and ZIP code)
: EdSignature o utho zec Re ee / � !Date(month. day.year)
Address of Au h )zed Repr senta ._ -_^fiber and-fret.c i.state and ZIP
3 s., - Date(month.day.year)
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DISTRIBUTION: Original-County Auditor, File-Stamped Copy-Taxpayer
