Age_Parish Reset Form
""" APPLICATION FOR SENIOR CITIZEN
a , •� COUNTY TOWNSHIP YEAR
``" A I► PROPERTY TAX BENEFITS
\ Stale Form 43708(R18/9-24) ✓O 0 Q ` 7�} Zr
tam Prescribed by the Department of Local Government Finance c� U v "'
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 the all that apply)
Name f Applicant(owner or Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
c nt ct er Telephone Number ///Em��ailAddress
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 Under Recorded 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 Property in Question:
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
b 2_ 11- 12— '2.+OZ--002. 1I-V3-022 .
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 alter December 31,2019 and before January 1,2023,
Yes ❑ No and$239,999[all Indiana real
$
annually adjusted.]See reverse for details.
Have You Filed for Any the eductions? If Yes Wh De actions?
El Yes ❑ No
-
Have You Filed for De. ct•n in Any Other County? If Yes,Whounty?
❑ Yes ❑ No
‘.4)1.4)\ .
I/We ce i under penalty of perjury that the above and foregoing information is true and correct. ✓
Xign re Applicant D e(month,dye
Address of Applica t(number nit street, 'ty,state,and ZIP code) -Slag _ `s
Signature of Authorized Representative ! Dale(month Y�e� 1 ,
Address of Authorized Representative(number and street,city,state,and ZIP code) 'rlGny�0 �\
9
Signature of Cou dito Date(m t ,d year)
1 ) • 1 r-2,-02-) '
DISTRIBUTION: Original—County Auditor,File-Stamped Copy—Taxpayer •