Age_Finney Tisi APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
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PROPERTY TAX BENEFITS �Z
State Form 43708(R16/1-23) 3 o 009 _ `
_i• Prescribed 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 property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Type of Benefit Requested(Please check I that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of Atoplica t owner or cont ct b yer) Telephone Number ///Email Address
'3eYtnv A Q_A\lc (g 12 ) 6 04 O 3-z
Is Applicant th S e r Equitable Own If No,What is His/Her Exact Share or Interest? - If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
❑ Yes ❑ No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
❑ Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
One(1)Year before Claiming Deduction? ❑ Yes ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Pr erty in Question:
eal Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District 0 Key Number/Legal Description Record Number Page Number
23-1 g_36-vt03-,000 ,yi3--o c
Does Applicant Reside on Property? Assessed value of the property as of current year assessment date'Way 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 1,2020,and$199,999[al
Yes ❑ No Indiana real property]for
Yes El No
Have You Filed for D)(Yes
in Any Other County? If Yes,What
❑Yes No
I/We certify under penalty of perjury at the above and foregoing information is true and correct.
XSignature of Applicant !' Date(month.day,year)
PI.dittleit4tH can�[ r and sire ,city,state,and ZI c J Ian .D1n —
Signature of Authorized Represent Date(month,day,year)
Address of Authorized Representative(number and street,c10(1 snieity,state,and ZIP code)
-0 Signature of County dit Date(month, a�
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MN
2 3 2024
DISTRIBUTION: Original—County Auditor; File-Stamped Copy'y �
-Taxpayer a,
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