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�,` "'rf�L APPLICATION FOR SENIOR CITLED COUNTY TOWNSHIP YEAR
' y PROPERTY TAX BENEFITS I
',.46. 7 State Form 43708 (R19 /7-25) i /( ( DcI 'ic:::2 :,)
's,• Prescribed by the Department of Local Government Finance D ��++ o QQ?55
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1�359.
Instructions: To be filed in person or by mail with the cot,auditor of the count where the property is located.
Filing Date: Form must be completed, signed, and filed ( grtik!zta.4rked by January 15 of the calendar year in
which the property taxes are first due and p:y T` AUDITOR
See reverse side for additional instructions and qualifications.
Type of Benefit Requested (Please check all that apply) /
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Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer)
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Interest?Applicant the Sole Legal or Equitable Owner? If No, What is Applicant's Exact Share or If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
ElYes ❑ No
If Name on Record is Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
gl 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?
ayes o
Address of Contract Seller (number and street, city, state, and ZIP code) Is the Property in Question:
Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District Key Number/ Legal Description Record Number Page Number
.W9 gTirrn 916- c',2.d2-0i-col -x6 , dg1 - 6oq _
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 n 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? EYes ❑ No
$
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant Date (month, day, year)
v4-1. *gt-r n7c� Aeti (i ) J _ �/
Address ofApplicant(number' d street, city, state, d ZIP code
-0Cvt� /8 b7-14-1)7-:67W 39
Signature of Authorized Representative Date (month day, year _ r
7 o�L{�/'�a�jam"
Address of Authorized Representative (number and street, city, state, and ZIP code)
Sign u of County Auditor Date (mont day, y ar)
' 'tii-ei /a 6 Y/PlAc*.f0 _
DISTRIBUTION: Original — County Auditor; File-Stamped Copy — Taxpayer