Age_Rupp Reset-Form`.
"-,"'w APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
OF3' PROPERTY TAX BENEFITS r1
is State Form 43706(Rib 19-24) /__•t n 5C \ �f was
Prescribed by the Department of Local Government Finance V�/
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 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 check all that apply)
Over 65 Deduction from Assessed Valuation faY6ver 65 Circuit Breaker Credit
Name of Applicant(owner or contract buyer)
Is Applicant the
Solele Legal or u table Owner? If No,What Is His/Her Exact Share or Interest? t If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
L3YYes ❑ No
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
E�YPes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
One(1)Year before Claiming Deduction? L1'Yes ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question:
[L.fro/al Property El Mobile Home(IC 6-1.1-7)
Taxing D strict Key Number/Legal Description Record Number Page Number
J 0\(MO cOU -as- 13-0 00- 000 . --)kaq-oaL)
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(all
/ Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019 and before January 1,2023,
L�d'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 Years of Age or More on December 31 o e Year Prior
Yes ❑ Nome____ ' e.0-01
Have You Filed for Deduction in Any Other County? If Yes,What County?
❑ Yes to
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Appli Date(month,day,year)
Address p' (numberand street,city,sta ,and co
I 0\-1 S_ Wes. c� - •
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(month,day,yeT ED
L- ate ,�� c- 3- �- L
MAR 14 202
DISTRIBUTION: Original—County Auditor;File-Stamped Copy—Taxpayer
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GIBSON COUNTY AUDITOR