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-" 0"''.a: APPLICATION FOR SENIOR CITIZEN
` `'��`'� ��� PROPERTY TAX BENEFITS co NTY TOWNSHIP YEAR
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.�� ,,/� State Form 43708 (R19 /7-25) - Si°V\ O2. �2Prescribed 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 ec all that apply)
Over 65 Credit Over 65 Circuit Breaker Credit
Name of Applicant (owner or contr t b er) Telephone Number rr'E ail Address
o n'na, Ill WV) S . ( )
Is Applicant the Sole Legal or Equitable Owner'? If No. What is Applicants Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
!gl Yes 0 No
If Name on •ec• d 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 Pr Under Recorded Contract
for at Least One(1)Year before Claiming Cr it?
Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code) Is the Property in Question:
Real Property ❑ Mobile Home (/C 6-1.1-7)
Taxing District Key Number/ Legal Description Record Number Page Number
o2S' 26-•12 ^08 -col 002 .5io-- 1324
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?
1s the Applicant 65 Years of Age or More on December 31 of the Year Pnor 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.
Signature of Applicant , , Date (month, day, year)
060)52( 1 4rodra �r11
Address of Applicantand reef, city. state, and ZIP code) CA
I Ig ,S 6- )I:\3-\(116 ottt n St R ‘-\); 0 _ N — LO--0-1)
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Signature of Authorized Representative } Date (month. day. year) n c
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0 C (�
7 �l
Address of Authonzed Representative (number and street, city, state, and ZiP code) • Ntiligill
C O
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Signature of County Auditor Date (month, ay, ye r)
f�� t\l 12 30 1,o -
DISTRIBUTION: Original — County Auditor: File-Stamped Copy — Taxpayer