Age_Simmons Reset,Form
"N APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
4f� :- �q PROPERTY TAX BENEFITS
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State Form 43708(R18/9-24) C_
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1816 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
Na f Applicant(owner or ntr ct b er) Telephone Number Em 'I Address
� own i� lmt�O �.
Is Applicant the Sole Legal or Equitable Owner? If No,What is His/Her Exact Share or Interest? 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 Unde R rded 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 roperty in Question;
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key N mber I Legal Description Record Number Page Number
02Z • Zc- $,-0-7 - 101 - 000 , 11-7- -022_ .
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 am of Age or More on December 1 of the Year Prior
$
annually adjusted,)See reverse for details.
Have You Filed for Any Other Deductions? If Yes,What Dedu ions?
Yes ❑ No
Have You Flied for De on in Any Other Cou ty? If Yes,What Cou 7
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❑ Yes No S. '," •(lic
I/We certify under penalty of perjury th t the above and foregoing information is true and cots • I,' A`{ `m}
Signature pplicant Mel'•.onth,day,yeae
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Address of Applicant(number an s reet,city,state,an co e)
Signature of Authorized Representative Date(month,a )
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of Count Audit r Daton day,y aj �—
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DISTRIBUTION: Original—County Auditor;File-Stamped Copy—Taxpayer