Age_Hurst Ri trForm
"_`" APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
74 - PROPERTY TAX BENEFITS
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... ---, State Form 43708(R18/9-24)
" rb'• Prescribed by the Department of Local Government Finance - '`- Pe:, 'co( e_ 'l. &)A ,
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 checkkal that apply) -
LtVOver 65
with Joint Tenant or Tenant in Common,Indicate with Whom
�es ' ❑ No
If Name o Record is Different than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
1 (. 1 11JdnRYes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Reco d 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 Property in Question:
eat Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page,Number
NC—C-1(Q. i —Q — I l — —� k 0I -im l - o�r1-i c- ?
Does Applicant Reside on Property? Assessed value of t a 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,
LTIC ❑ 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 he Year Prior '
46
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Have You Filed for Deduction in Any Other County? If Yes,What County? ip/
❑ Yes LtYNo O 999
IIWe certify under penalty of perjury that the above and foregoing information is true and correct. /e`SON CO``S
Signatur • ..IicarR-N—, Date(month,day,year) c/
\A—‘0 —
Address of Applicant(number an street, ,and ZIP code) �1 ,
3(Cr icy • F'JL-_• '(.CC�- � . °R
Signature of Authorize Representative ) Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Ignature of County Auditor Date(month,day,year)
..)(\al, i Q a ,..08.3-L.,„D-7„, 0
DISTRIBUTION: Original—County Auditor,File-Stamped Copy—Taxpayer