Age_Davis (34) APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
4 --'--A PROPERTY TAX BENEFITS
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4 1111!,: State Form 43708(R16/1-23) OP30ve-) CO 2_- ' . ?•-'02._(1
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'81. 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 che k all that apply))(
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
awe of Applic t(owner or contract b yer)
Owned with Joint Tenant or Tenant in Common,Indicate with Whom
CI Yes El No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
0 Yes CI IV 0
Name of Contract Seller 'Has Applicant Owned or Bought the Property Un er corded Contract for at Least
One(1)Year before Claiming Deduction? Yes 0 No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Qu tion:
eal Property C] Mobile Home(IC 6-1.1-7)
Taxing District . Key Number!Legal Description Record Number Page Number
(0 V2_—0? -?-00-000, Lt
Does Applicant Re .de 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 1,2020,and$199,999[al
Yes ill No _Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the Applican 65 ear of Age or More on December 31 of the Year Prior
$
Have You Filed for Any Other Deductions': If Yes at Deductions?
ion
ID ,No
Have You Filed for De ion in Any Othei.,. 110? If Yes,What County?
Dyes No 007
.8 vf
e certify unde enalty of perjury t t the above and foregoing information is true and correct.
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ignature of Applica Date Frtgre-ereuvr)
Address of Applicant(number and street,city,state,and ZIP code)
K nl— S V-12k e_ c ? -
../ Date(month,day,year)
Si lure of Authorized Re r en ative
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4.2411.0-- 1/D60,7--6---
ddress of Auth 'zed Rep esentative(num nd st eet,city,state,and ZIP code)
Signature of Co ty Audit icy\
---) Date(month,d
DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer