Age_Hensley (2) Reset Form
..-r APPLICATION FOR SENIOR CITIZEN OUNTY TOWNSHIP YEAR
�l`4 PROPERTYState Form 43708RTAX BENEFITS
18
/9-24)
0Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
V 2..._--.
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,signed,and filed with the county auditor or postmarked by January 15 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 heck all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
t�faF'i5of Ap "cant(e or yer) Telephone Nu ber E ail Address
Is Applicant e S le Legal or Equitaber? 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 d is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
El 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 the P operty in Question:
eal Property El Mobile Home(IC 6-1.1-7)
Taxing District Ke ber/Legal Description Record Number Page Number
C)'Z' -- Nl-kr ko o- pep. cli- 0 27?- -
Does Appiica Res eon Property? Assessed value of the property as of current year assessment date(May not exceed$240,000 for Over 65 Deduction or
$199,999[counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,$/99,999[all
Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019 and before January 1,2023,
Yes ❑ No and$239,999[all Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2022.)See
I/We certify under penalty of perjury t t t above and foregoing information is true and correct. t
Signaturg)of Applicant Date(month,dr yt yea`y'
Addr ss of Applicant(number street,cit state,and ZIP /1
Signature of Authorized Representative Date(month,FIT ifED
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of Co ty Aud" p R.)
Date(month,day AN 1 2025 i,c,::3" .
GIBSON�7� t'..�. ,�v
DISTRIBUTION: Original—County Auditor;File-Stamped Copy—Taxpayer