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-r,!`(4. APPLICATION FOR SENIOR CITIZEN
COUNTY TOWNSHIP T YEAR
(�- PROPERTY TAX BENEFITS �j
;/ State Form 43708 (R1917-25)
!Ito,.
e We Prescribed1 ---�
by the Department of Local Government Finance Ce-) t\Qaf\ j
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 postmark() January 15 of the calendar year in
which the property faxes are first due and payable.
See reverse side for additional instructions and qualifications. ..1
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Type of Benefit Requested (Please check all that apply) ----� t,..3)111n1)All>6 /1)Tvc\v) 4 T_
----
111<cver 65 Credit ..) Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer) Telephone Number Email Address
L..,\\ 03 1 kz . .. ( \ \ ,
IS Appfic e Sole Legal or Equitable Owner? If No, What is Applicant's Exa ar or erect? If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
f
❑Yes No I
If Name on Record is Different than Applicant, Indicate Below 6-10 All Dint Tenants or Tenants in Common Reside on the Property?
?Cues ❑ No
Name of Contract Seller L 03 2D Has Applicant Owned or Bought the Property Under Recorded Contract
�5 for at Least One(1)Year before Claiming Credit?.
'' -';2 es ❑ No
Address of Contract Seller (number and street, city, state, and ZIP cod '! �. Is the Property in Question:
tY � es�a p/y
OV •N ,Q�'` . 0RBaI Property ❑ Mobile Home (iC 6-1.1-7)
Taxing District Key Number/ Legal Description �4UQI�O Record Number Page Number
P6icl\AJ
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 IZI ' es ❑ 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? eyes ❑ No
$
IIWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant Date (month, day, year)
� i 1 -� -ate
ddress of Ap ' ant (number and street, city, sta .
and ZIP code)
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Signature of Authonze epresen g ` Date (month, day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code)
Signature of County Auditor •All!, Date (month, day, year)
•
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DISTRIBUTION: Original - County Auditor; File-Stamped Copy - Taxpayer