Age_Cummins ResetTbrlm'
d`.:R"'q APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR.
a'�- t PROPERTY TAX BENEFITS
P _•y State Form 43708(RiB/9-24) J T�,/�1 , O
• 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 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 Over 65 Circuit Breaker Credit
Name( fApplict(ownerorcorrtra /
ct yer)
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 Und Recorded 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 the P operty in Question:
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
C)2- -- . 76- 0c 31-700-000 3 i 2 •
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 ears of Age or More on Decem r of the Year Prior
,`
G es ❑ No J J
Have You Filed for D:•ucti.'in Any Other Con ? If Yes,What County?
❑ Yes No Nell
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
S' ure o App' nt , Date(month,day,ye Yl
cs \'‘ 111/41:1(1
Address of Applicant(number and streeL cftiv,,state,and ZIP code) Q.
. 0 rb....1., 161
Signature of Authorized Representative • Date(month,day,year) GiyQ
-V
Address of Authorized Representative(number and street,city,state,and ZIP code) Q
Signature of County ditor I Date(month,day year) 0�
.(Y) 11) (q., 1 L-I 1? '702.3 ,
DISTRIBUTION: Original—County Auditor;File-Stamped Copy—Taxpayer