Age_Clark \-\-V,/1 R eset gForm
a °c APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
- •4 PROPERTY TAX BENEFITS
.�,�;�� State Form 43708(R18/9-24) G`1650 4 ��
Prescribed by the Department of Local Government Finance Piire)
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 TT •
Filing Date: Form must be completed,signed,and filed with the county auditor or postmarked by January 15 he c n r.ye r
which the property taxes are first due and payable.
LISee reverse side for additional instructions and qualifications.
Type of Benefit Requested(Please check all that apply) MAR ?6 2D�5
Over 65 Deduction from Assessed Valuation Over 65 Circ r repker Credit
Na a of Applicant(owner contract buyer) Email Address1),
Is Applicant a So Legal or Equitable Owner? . If No.What is His/Her Exact Share or Interest? If Owned with Joint Tenant or Tennan'Pin r�to with Whom
Yes ❑ No TOR
If N e on Record is Di rent thanT Ap/pli^t,Indicate Below
Do All Joint Tenants or Tenants In Common Reside on the Property?
>C /�I y �L kc Yes ❑ No
Name of Contract Se er / 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 Property in Question:
'Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Le Gal 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[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
reverse for details.
Is the Applicant 65 Years of Age or More on December 31 of the Year Prior
?
NI Yes ❑ No /U, f Ekb
Have You Filed for Deduction in Any Other County? If Yes,What County?
❑ Yes CNo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant (month,day,year)
CQ.� ,•r: :// ' C',� � Date , - . L - a.5
Addres of ApplicaRM er and street,city,staK an/i ZIP code
Signature of Authorized Representative Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Sign to orCo tn# Audtor y " Date(monO,day,yea),
EOS/ a.°
, /l'icrk
DISTRIBUTION: Original—County Auditor;File-Stamped Copy—Taxpayer