Age_McDowell , t"'ro�4 APPLICATION FOR SENIOR CITIZEN co�t.fNTY TOWNSHIP( 03/C) ()() 6 YEAR
�; .-- PROPERTY TAX BENEFITS
"'T""' /� State Form 43708(R16/1-23)
°'° Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
/Lk?INSTRUCTIONS: To be filed in person or by mail with the county auditor of the county where the property is logq d. �r
FilingDate: Form must be completed and signed byDecember 31 and filed with the countyaudit U�` is }rillqwin p g postmarked �` C g
January 5 of the calendar year in which the property taxes are first due and payable.a%Q `mac C¢
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See reverse side for additional instructions and qualifications. N C Q / 's'1
Type of Benefit Requested(Please check
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all that apply) 40r,,
L�Oer 65 Deduction from Assessed Valuation 'Over 65 Circuit Breaker Credit R
Name of Applicant(owner or contract buyer) Telephone
If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
LSYes ❑ No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
L 'eson� ❑ No.
Name of Contract,I Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
IX ( One(1)Year before Claiming Deduction? es ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question!
[ ' eal Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
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 received before January 1,2020,and$199,999(al
LLI/Yes ❑ No Indiana real properly)for the Over 65 Circuit Breaker Credit initially applied for after December31,2019.)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 D uctions7 If Yes,What Deductions? 7�
es ❑No 9 es`�Q1`ne -0 ell
Have You Filed for Deduction in Any Other County? If Yes,What County?
❑Yes 90
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant f Date(month,day,year)
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, ,D LJ - 1, i-Yr—Z9 l) A, C41 1"— ILL?- L4 .
Address of Applicant(number and street,city,state,and ZIP code)
Signature of Authorized Representativ t Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of County Auditor Date(month,day,year)
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DISTRIBUTION: Original—County Auditor; File-Stamped Copy—Taxpayer