Age_Simmons ,,,,,„t 1,„P4. APPLICATION FOR SENIOR CITIZEN
*d _ COUNTY TOWNSHIP YEAR
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PROPERTY TAX BENEFITS
1,!,,itsofr State Form 43708 (R19 /7-25) CD 21 ?____
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 e all that apply) /
Over 65 Credit ver 65 Circuit Breaker Credit
Name of Applicant (ow r or contra b er)
If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
Yes ❑ No
If Name on Jc d is Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in Comm•n Reside on the Property?
I1 Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the • ..• % Under Recorded Contract
for at Least One(1)Year before Claimi . edit?
III Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code) Is t e Property in Question:
Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing Distnct Key Number I Legal Description Record Number Page Number
(DV .
6. — 1 7 — 44 C 0 —0 0 2--'-1 -0 '7,
Did Applicant qualify for the homestead standard deduction in the preceding year (or was applicant married 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 ❑ 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 Prior to the Year Taxes are First Due& Payable? Yes El No
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I/We certify under penalty of perjury that the above and foregoing information is true and correct. pitb
Si ure of Applicant Date (month, day, year)
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Address of Ap licant (num r and street, city, state, and ZIP code) NO '\DE)k c•-) soo 0 NiA\e - '7)C - -)\-) u6Yr
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Signature of Authorized Representative ) Date (month, day, yepir-
6'.161SOili C hiyi
Address of Authorized Representative (number and street, city, state, and ZIP code) 0/ -
Signature of County Auditor Date (mo th, day.year) D�
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DISTRIBUTION: Original — County Auditor; File-Stamped Copy — Taxpayer