Age_Wirth (8) ,,.4,. ''a. APPLICATION FOR SENIOR CITIZEN -
COUNTY TOWNSHIP YEAR
., PROPERTY TAX BENEFITS I —
�. Stale Form 43706(R16/1 I I
.s0 j 0 284
•. Prescribed by the Department of Local Gc ero ,er t Fria-c= .
�
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
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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 postmar bythe wine
January 5 of the calendar year in which the property
- 0 --— - —
'Over 65 Deduction from Assessed Valuation Tj' '
Over 65 Circuit Breaker Cre
e A I•ca^t fo c'b er; Telephone Number r
E a l Address ��
( )
Is Applicant the Sole Legal or Equitable Owner' If No.What is His-Her Exact Share or 1-:erest? If Owned with Joint Tenant or Tens,! :--r-non•Indicate with Whom ,
Yes _ No
i If Name on Record is afferent than Applicant.Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
__ T. Yes _ No
Name of Corhact Seller Has Applicant Owned or Bought the Property Un er ecorded Contract for at Least
One(1)Year before Claiming Deduction? Yes _ _ No
Address of Contract Seller(number and street city. state and ZIP code! I Is the roperty in Quo ,on- - —
1
I _ Real Property _ Mobile Home(IC 6-1.1-7)
Taxing District ' Key Nurbber'Leioal Description Record Number Page Number
O 213 26- p-- 1$ --�-0�- uo).231- -0 2s .
Does Apptcant R de on Property? Asses ed valu of the property as of current year assessment date(May not exceed$240.000 for Over 65 Deduction or
$199.999(coun.ingjust the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,202G and$199,999[al
Yes — No Indiana real property]for the Over
Have You Filed for: ;:::t:::
ny j ff Y : tbo\
❑N �/HaveYou Fled for ounty If Yes. hat ou .. 1 - — --
ElYes No i
I/We certify under penalty of perjury at f bove and foregoing information is true and correct.
•gnature of Applicant ( 'ate(month. day.year)
sit b<tl
A dress of pp:cant(number and street. cdy state. and ZIP ccde,I ----- -
Signature of Authorized Representative Date(month da,•
Address of Authorized Representative(number and street.cty.state and ZIP cone
,
i
garghature of Court .4ud•^r 'Date Imo day ear, 1
L iliel‘j\J in_s-72- i
DISTRIBUTION: Original-County Auditor. File-Stamped Copy-Taxpayer