Age_Belcher (2) I Reset Form
dam"'' APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
4 -- " �s PROPERTY TAX BENEFITS r
;:,� State Form 43708(R18/9 24) 5
o� -� /�sueC:)2_t ' 202
iota 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
me of Applicant(owner or cool ct uyer) Telephone Number Erail Address
If
Is pplica the Sol= egal or Equitable Owner? If No,What is His/Her Exact Share or Interest? Owned with Joint Tenant or Tenant in Common,Indicate with Whom
►.� Yes ❑ No
If Name o - ..'s 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? C es ❑ No
Address of Contract Seller(number and street,city,state,and ZIP code) - Is the Property in Question:
XReal
Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District KeyNumber/Legal Description Record Number Page Number
02� • ?-6-11-12--1a2 00071303 -02-3 .
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 Years of Age or More on December 31 of the Year Prior
F IL EDYes ElNo ' '
Have You Filed for D 'on in Any Other C un ? If Yes, at County?
❑ Yes No
// \\ JUL 2.1 2025
I/We certi and r penalty of perjury that the above and foregoing information is true and correct.
Sign to of C > Date(month,day,year)
Xdd.
of Ap licant(number n eel,city,state,and ZIP code) GIBSON(:OUN I Y AUDI I OH
21 SCC tkSi- r io n - ,Dn- Li 6 -
Signature of Authorized Representative) Date(month,day,year)
Address of Authorized Representative(number and streetq . ,city,state,and ZIP code) _
Signature of Cou ty Au ilor Date(m nth,da ,year)
m \t�s - �1� 2 --.
- DISTRIBUTION: Original-County Auditor;File-Stamped Copy-Taxpayer