Age_Abner Rteset,F0,01
r "4 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
07-'
51 ;= PROPERTY TAX BENEFITS +. A
�� State Form 4370E(R1B/9-24) C.t ( ■ . A)D.
'•'• .... Prescribed by the Department of Local Government Finance 1 r`""'Y) •
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. T
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)
Id Ockver 65
If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
eS ❑ 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 Under Recorded Contract for at Least
One(1)Year before Claiming Deduction? I]� ' ❑ No
Address of Contract Seller(number and street,city,state,and ZiP code) Is the Property in Question:
C'eal Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
Pa — au). _ OS-r►-kQ - a1\- c I- Ott-Q X
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 fall
Indiana real property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019 and before January 1,2023,
[ es ❑ 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
es CINo4
Have You Filed for Deduction in Any Other County? If Yes,What County?
0 Yes rUI/No kik '44e)
I/We certify under penalty of perjury that the above and foregoing information is true and correct. . 08
Siggat a of Applicant Date(mo r) CQ�C
V Address of Applicant(number and street,city,state,and ZIP code)
30`1. \•c7 , 'D-� ..i) • . '--l' cs46Z:o
Signature of Authorized Representative Date(month,day,year) 9 `
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of County Auditor Date(month,day,year)
4r•N)eico Q 8 .0 } luAir40, -2. - a'S .
DISTRIBUTION: Original-County Auditor;File-Stamped Copy-Taxpayer