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`"""a APPLICATION FOR SENIOR CITIZEN
��� COUNTY TOWNSHIP YEAR
-:—. 4.= PROPERTY TAX BENEFITS 1 ^ `�
ttt..,- State Form 43708(R18/9-24) 3o(\ O / 7t �2
01 --
D Prescribed by the Department of Local Government Finance !�CCCJJJ
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
u be
N me of Appli t(owner or co ct b er) Telep / E rl Address
Is Applicant th Sole Le al or Equitable t? er? If No, a is His/Her Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common,Indicate with Whom
❑ Yes El No AUG 5-5If Name on Record is Different than Applicant,Indicate Below G " Do All Joint Tenants or Tenants in Common Reside on the Property?
❑ Yes ❑ No
Name of Contract Seller �//^�J iiir1as Applicant Owned or Bought the Property der corded Contract for at Least
(,��i, (lCnuNTM AUDtTC) One(1)Year before Claiming Deduction? Yes ❑ No
Address of Contract Seller(number and street,city,state,and 1W)w Is t e Property in Question:
Real Property ❑ Mobile Home(IC 6-1.1-7)
Taxing District Ke Number/Legal Description Record Number Page Number
. O� • cA 12-01—IOI— OO .3) O 18'
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,
ffes ❑ No and$239,999[all Indiana real
Have You Filed for D u lion in Any Other County If Yes,What County?
❑ Yes No
I/We certify under penalty of perjury th t t e ab ve and fore g info ation is true and Xcorrect.
Sig a of Applicant Date(month,day,year)
A dress t(number t,city,s ate and ZIP de) 41(4441
Signature oflAuthori Representative Date(month,day,year)
Address of Authorized Representative(number and street,city,state,and ZIP code)
Signature of Coun Auditor (��, ` Date( nth day,year)
DISTRIBUTION: Original—County Auditor;File-Stamped Copy—Taxpayer •