Age_Robling ,,r.9, APPLICATION FOR SENIOR CITIZEN --
OUNTY I TOWNSHIP
. YEAR
y PROPERTY TAX BENEFITS t
State Form 43708(R16/1-23;
,e•_- P ;e_ e Department of Local Cc Bern F-na^.ce 6 V"� I i
Li
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
j Name Appfca-t rosy-'e- c;rtra t yer' I Telephone Number
E al Address
C111). R \k'QW11G (
Is A-. _ the Sole Legal c' :'"able O'.ner? If No,What is His'Her Exact Share or Interest? If Owned with Joint Tenant Cr Tenant in Common,Indicate with Whom
Yes _ No
If Na-nne c^Record is D.ffe-ent than Applicant.Indicate Belo' Do All Joint Tenants or Tenants in Common Reside on the Property? '
_ _ Yes No
Name of Contract Seller I Has Applicant Owned or Bougrt the Property Under Recorded Contact for at Least
i One(1)Year before Claiming Deduction? _ Yes _ No
Address o'Contract Seller(number and street city state and ZIP code' I Is e roperty in Question
Real Property _ Mobile Home(IC 6-1.1-7)
Taxing District 'Key Nu ber i Legal Descr,• Record Number Page Number
CO . 2 6- 12-11-)-Zoo -0 00. 624_ bbLi
Does Applicant Reside on Pro rty? 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 1.202G. and S199,999(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:cart 65 Year of A or D ore on December 1 of the Year Pnor
Have You Filed for Any er Deductions? j f , irh�t Deductions? — --
Yes El No
Have YouFled for D du on in Ary Other unt •
; If Ye,.What County?
'4) .
❑yes No I . -
II V'e certify under penalty of perjury at th above and foregoing information is true and correct. *A '''
Signature `Aprlica 10 \ ' Q Date(moot . Jr/.year)—.6—
AItr (VII CO, '1 sbro Zee' Address of scan?(numbl.nit street. city state and ZIdel Q
LID E S`v S - 4iii,..e-- a
Signature of Aothonzed Representative ' Date(month •:r )
Address of Authorized Representative(number and street state and ZIP code
S graure o'Co.rty ALr!'tor Date im nth day
mtiKA An (10
S I n 111 .
✓n 11_,...._,::\ I IN 1 v1 i -Dei)c,ii\-i al
DISTRIBUTION: Original-County Auditor, File-Stamped Copy-Taxpayer