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Age_Shaw Q* ".\ APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR t ' 11 PROPERTY TAX BENEFITS /l_ - s..f/ State Form 43708(R16/1-23) arAot,3 AdaQvae oN \ra" 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 th folio in January 5 of the calendar year in which the property taxes are first due and payable. �- See reverse side for additional instructions and qualifications. NO v , 2�24 Type of Benefit Requested(Please check all that apply) 1� Over 65 Deduction from Assessed Valuation 1�x Over 65 Circuit Br1,C�edit, `�Namme/o�fApppllicannti(ow eror �ontraccttbuy�er) If Owned with Joint Tenant or Tenant in Common,Indicate with Whom , Has Applicant Owned or Bought the Property Under Recorded Contract for at Least One(1)Year before Claiming Deduction? D'Yes ❑ No Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question: Real Property ❑ Mobile Home(IC 6-1.1-7) Taxing District Key Number/Legal Description Record Number Page Number r O� --i"7-3? 3, 0-v©is7(s-oal Does Applicant Reside 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 XYes ❑ No Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details. Is the Applicant 65 Year of Age or More on December 31 of the Year Prior $ Have You Filed for Any Other Deductions? If Yes,What D uctions? ) gYes ❑No CE.- Have You Filed for Deduction in Any Other County? If Yes,What County? ❑yes (Otto VW ' under penalty of pen a h above and foregoing information is true and correct. 1 'Signature of p' nt Date(mont ,day,y r) Address of App icant(n ber pad stree,city,sta e,and c de) /04, 3a , OR ito 5' ativi r_t, ) / 1&o. Signature of Authorized Representative Date(month,day,year) Address of Authorized Representative(number and street,city,state,and ZiP code) r 0 Signa ur of/ bounty Auditor /� i� Date(mo h,day,year) j /mil/A/t`y/ja ,�I// i 13 /c9 a0/1-//t/'