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` Ir, - APPLICATION FOR SENIOR CITIZENg .._. 1 COUNTY TOWNSHIP I YEAR
' 1 PROPERTY TAX BENEFITSLj\ f
.� �; : State Form 43708 (R18 19-24) FILn � Pp.
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`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 wher i, property is boa.467t)
Filing Date: Form must be completed, signed, and filed with the county auditor or postmarked 2y ry 15 of the calendar year in
which the property taxes are first due and payable. "<�
C Over 65 Circ it Breaker Credit
Name of Applicant (owner or contract buyer) Telephone Number 3 6. 5-- 3 0 9 Email Address
Bcn, Ie S, rfl c Co ut)e-C ( L rr cr b o ii A i e. CI- a mori it. Gam
Is Applicant the Sole Legal or Equitable Owner? If No, What is His/Her Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
Yes ❑ No
if Name on Record is Different than Applicant, Indicate Below Do All Joint Tenants c�T - s in mmon eside on the Property?
/ Yes X No
Name of Contract Seller Has Applicant Owned or Bougtthe Pro Unde Recorded Contract for at Least
One (1)Year before Claiming Deduction? ' 1 Yes n No
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
PQ e�Cf . Lo -- ( --C 'R - t 03- 00 - 2., L0- 0
Does Applicant Reside on Property? ssessed value of the property as of current year assessment date (May not exceed $240,000 for Over 65 Deduction or
$199,999 [counting just the homestead site]for the Over 65 Circuit Breaker Credit received before January 1, 2020, $199,999[all
Indiana real property] for the Over 65 Circuit Breaker Credit initially applied for after December 31, 2019 and before January 1, 2023,
iN Yes C No and$239,999 fall Indiana real property]for the Over 65 Circuit Breaker Credit initially applied for after December 31. 2022.) See
-
Have You Filed for Deduction in Any Other County? If Yes, What County?
❑ Yes De
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of A licant Date (m nth, day. year)
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1.5 010k(1, ,,,2, `i ' „ ) a a 0 _
Address of Applicant (number and street, city, state, and ZIP code)
CIO E • 1AT 51. R CZ t 6) D /v , 47 4 -7 0
Signature of Authorized Representative Date (month. day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code)
Signature of County Auditor n Date (month. day, year)
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DISTRIBUTION: Original - County Auditor; File-Stamped Copy - Taxpayer