Age_Goldsberry Resy'v,m
et Form
•
k. "-;� , APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
1
s� - '•• 1 PROPERTY TAX BENEFITS r
,11
. `,/ State Form 43708(R18/9-24) 3'1� oD V !N2_5-.
I°'• 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,signed,and filed with the county,
` ( `�
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Nam of Ap licant(owneror o r ct b e Telephone Number it Address
Elite ( )
s App egal or citable 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 the roperty in Question:
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Ke 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 Credit received before January 1,2020,$199,999 tall
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
reverse for details.
Is the Applicant 65 ears of Age or More on December 31 of the Year Prior
f )
s ❑ No ���}l1lh�''" I
Have You Filed for De in Any Other Coun ? If Yes,What County? Yj enr"...5
ElYes No ' �+
INVe certify under penalty of perjury t at th above and foregoing Information is true and correct.
2'I���Z s Signature of Applicant...f Al Date(month,day,year) i
ertPtt
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ess of Applicant(number and street city,state,and ZIP code)
ct \ t y Us/ °I tgnA , -- 30 — Lf 6 0 • FFB?o?o
gnature of Authorized Representative Date(month, year) <J
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Address of Authorized Representative(number and street,city,state,and ZIP code) 11 CO CO
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Signature of ounty A r I Date(month ay,y ar) Oq
\I 7i 20�1,c)2 > .
DISTRIBUTION: Original—County Auditor;File-Stamped Copy—Taxpayer