Age_Jones Po. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
4-• e- PROPERTY TAX BENEFITS
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. ;'/ State Form 43708(R16!1-23) ,J\ (1 - '��
ilia 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
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name
�of Ap licant(owner or con act b yer) Telephone Number m -I Address
1' 'l a J -n67-. • ( )
Is Applicant the Sole Legal or Equitable Owner? 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? D Yes ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is t operty in Question:
eat Property ❑ Mobile Home(IC 6-1.1-7)
Taxing Di trict Key Number/Legal Description Record Number Page Number
2�' 26_1Z--07_- LA o' oat, I J"b -0
Does Applican 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 ❑ 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 Year of Age or More on Decem•p I x''of the Year Prior
$
ve L• d' An'' Ih r Deductions?ii
If Yes,What Deductions?
" J Yes El No
.ve ou Filed for D u tion in Any Other C unty If Yes,Whdt County?
D"
❑Yes Nos
I/We certify under penalty of perjury t t t above and foregoing information is true and correct. µ'
ignature of Applica Date{A th,day,r�'� r
c,�o t"2� tiY
dress of Appli tuber nil reef,city,state,and ZIP co e tiCO 1-2
Signature of Authorized Representative / Date(month,day,ybarr -
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Address of Authorized Representative(number and street,city,state,and ZIP code) TO,Q
Signature of CC nty� Au itor Date(month,day,yearte�v1S (....c2
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N_S )1 Y1CA \nt:\--r___ sincQ01 0 1- -4-
DISTRIBUTION: Original—County Auld or File-Stamped Copy—Taxpayer 1W ci, 8_n ciii 1,a„.aL2_Zit /
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