Age_Hill .4.,c,'":44.. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
i4 -': \ PROPERTY TAX BENEFITS \ ,
,' State Form 43708 (R19 !7 2 C�� �/Q
`•i4 Prescnbed 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 properly taxes are first due and payable.
See reverse side for additional instructions and qualifications.
,
Type of Benefit Requested (Please ch k all that apply)
Over 65 Credit Over 65 Circuit Breaker Credit
Na a of Applicant (owner or contrac er) Telephone Number Em II Address
t'1 \ ' \\
Is At licant the Sole Legal or Equitable Owner? If No, What is Applicant's 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 Credit?
❑ 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 Distract Key Number/ Legal Description Record Number Page Number
0 � � 26- 12---1 —SO0-0O . ,LILk --00
Did Applicant qualify for the homestead standard deduction in the preceding year (or was applicant mamed at the time of death to
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead property in the immediately Ill Yes ❑ No
preceding calendar year) and does Applicant qualify for the homestead standard deduction in the current year?
is the Applicant 65 Years of Age or More on December 31 of the Year Pnor to the Year Taxes are First Due& Payable? Ili Yes 0 No
$
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
ignature of pplicant Date (month, day. year)
• C -- 7144Z- Le- i — 0 Z— — ?‘-+C).Z.
ddress of Applicant (number and street, city, state, and ZIP code) 0`. c iiiiit
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Signature of Authonzed Representative oi
y Date (month, day, yearE rn )111"..114
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Address of Authorized Representative (number and street, city, state, and ZIP code) z N
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Signature of County Auditor Date (month, d y, year)C
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DISTRIBUTION: Original — County Auditor: File-Stamped Copy - Taxpayer