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4 'T"', . APPLICATION FOR SENIOR CITIZEN
r '�``��� PROPERTY TAX BENEFITS couNTY TOWNSHIP YEAR
�sy..,/ State Form 43708(R19 / 7-25)
\ '°i! 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. I tak .'j
\,_ eft\Type of Benefit Requested (Please check all that apply)
Over 65 Credit Over 65 Circuit Breaker Credit
Name of Applicant (owner or contr buyer) Telephone Number Em it Address
S\e-Ni a L&ICrIn ( )
Is Applicant the 4 e 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
IN Yes ❑ No
If Name on R-co d is Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in Co non Reside on the Property,
Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the P Under Recorded Contract
for at Least One(1)Year before Claimin Cr it'?
es ❑ No
Address of Contract Seller (number and street. city, state, and ZIP code) Is the Property in Question
,Real Property ❑ Mobile Home (1C 6-1.1-7)
Taxing Distnct Key Number i Legal Description Record Number Page Number
OOI— • 26"-N — l'S -'04 - 001). i In ---00
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 properly 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 ❑ No
$
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signs of Applicant Date (month, day, year)
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ddress of Applican number and street, city. sta and ZIP code) 0
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limit
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Signature of Authorize epresentative Date (month, day. year) Z iT1 '''.11
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Address of Authorized Representative (number and street, city, state, and ZIP code) Z O
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Signature of County Auditor Date (month day, ye r) 8
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. 33 . . 1C10)
DISTRIBUTION: Original — County Auditor: File-Stamped Copy—Taxpayer