Age_Mellor �E� APPLICATION FOR SENIOR CITIZEN C UNTY TOWNSHIP YEAR
4. ; '91 x PROPERTY TAX BENEFITS
ti State Form 43708(R16/1-23) o -
Prescribed,- • ,,,,,,, CA ,31'.'1 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.O�l -�J�-"l`J Y Ok^l' \`rV/ lkL
Type of Benefit Requested(Pleas chec all that apply) 7
Over 65 D uction from Assessed Valuation Over 65 Circuit Breaker Credit
N e of Applicant owner or contr uyer)
,
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? ❑Yes ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is th P perty in Question:
eal Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Recotd Number Page Number
Does Applicant 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
AYes ❑ No Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the Applicaear of Age or More on December 31 f theYear Prior
A'o;es 0 No
Have You Filed for Den in Any Other Count ? If Yes,What((minty? o �'
..„,e;'):6
El Yes No G ��r
en
I/We certify under penalty of perjury that the above and foregoing information is true and correct SOiy eaegr
)c,
Si of Appli nt Date(mbrith,days
'CP
Ad less of pplicant(n m ar an street, ity, ate,and Z code) /'' 17.„1
5 5 kA S q ICY,.,yn _ ia-6
Signature of Authorized Representative ) Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of County Auditor Date( onth,d y,year)
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer