Age_Frohbieter / .
APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
a,:.,•- •:,1- PROPERTY TAX BENEFITS
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State Form 43708(R16 I 1-23) 2
13011
MI6 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 December31 and filed with the county auditor or postmarked by the following
January 5 of the calendar year in which the
Type of Benefit Requested(Please c k all that apply)
Ov 65 Deduction from Assessed Valuaticin Over 65 Circuit Breakertredit
Nameo1/4/..:c1kj::tcaS( n r contra t b er) Telephone Number m *I Address
(1_ )
IsI pplicant the S e Legal or -
n v71 t
e . If No,What is 711/Her Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common,Indicate withWhom
E]Yes -0 No
. .
If Name on Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
0 Yes 0 No
Name of Contract Seller Has Applicant Owned or Bought the Property Unde Recorded Contract for at Least
One(1)Year before Claiming Deduction? Yes 0 No
.Address of Contract Seller(number and street,city,state,arid ZIP code) Is e roperty in Ques n:
Real Property 0 Mobile Home(IC 6-1.1-7)
Taxing District Key.Number/Legal Description Record Number Page Number
OCIC ' 26-n- 31-30o-00o •(2-0 -0 0 el .
Does Applicant Reside on Property? Assessed value of the property as of current year assessment date(May not exceed$249,000 for Over 65 Deduction or
$199,999[counting justthe.homestead site]for the Over 65 Circuit Breaker Credit received before January 1,2020,and1199,999(a!
Yes 0 No Indiana real property]for the Over 65 Circuit Breaker Credit initiallyapplied for after December 31,2019.)See reverse for details.
Is the Applica 65 ar of Age or More on December 31 of the'Year Prior
$
Have You Filed-for Any•t •r Deductions? (Yes104ta Deductio 7
i Yes 0 No ,
Have You Filed for D,..ucti, in Any Other County? If Yes,Whar County?
Dyes El No
I/We certify under penalty of perjury that theabove and foregoing information is true and correct.
X Si nature Of Applicant . P-te(morith,day,!ydp)
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Address of Applicant(number and street,city,state,and ZIP code) 0 '
Sot Es. CrI30.1 Si- ittx.rio--_,n
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Signature of Authorized Representative ) Date(month,deif ;1
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.Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of ounty A -or Date(month,lay,yet)
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DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer