Age_Ferguson ResetA Form;
r-ttg, APPLICATION FOR SENIOR CITIZEN - COUNTY TOWNSHIP YEAR4: ri•= PROPERTY TAX BENEFITS \
.,� "" State Form 43706(R18/9-24) G COI` Q 9— X�--cJ
rem Prescribed by the Department of Local Government Finance CC��
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 c e all that apply)
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
r‘ille of ppli\'owner or corms t bu er)
If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
-❑ Yes Cl 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 Und corded Contract for at Least
One(1)Year before Claiming Deduction? es ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) Is he Property in Question:
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
029--- • 2C-12-16-g00 -001 .908' -0 24-
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 Yes 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 Decem December 1 of the Year Prior
es f: No
s � v
Have You Filed for D ct n in Any Other r.• ? If Yes,What County?
❑ Yes Ao
I/We certify under penalty of perjury that the above and foregoing information is true and correct. PI
Si ature of Applican Date(month,day,year)
(7'-''f- d "TS
leAlfre(WV1/L-
Adds of Zli nt(rum rand street,city,stateAarq ZIP code A
4'41
' 4re
Signature of Authorized Representative ) Date(mont , . ,year) Zo?s
Address of Authorized Representative(number and street,cit state,and ZIP code) 6s�bCo Q
Signature of County A itor Date( onth day,year qGcri
DISTRIBUTION: Original-County Auditor;File-Stamped Copy-Taxpayer