Age_Memmer
ct,"` APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP _ YEAR
'"'� �\
y PROPERTY TAX BENEFITS
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State Form 43708 R19 i 7-25) , 1( _br) 006 '7x)9___S—
'•.• Prescnbed 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
.
Type of Benefit Requested (Please • e all that apply) 1
WI Over 65 Credit Over 65 Circuit Breaker Credit j
Name of Apph nt owner or contra ct . yer) Telephone Number E it Address
' 2\ikr\t. llak 6
Is Applicant t e Legal or Equitable Owners�/ If No, What is Applicant's Exact Share or Interest? { If Owned with Joint Tenant or Tenant in Common, Indicate with Whom 1
Yes ❑No _ -------
If Name on R o is Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in C• on Reside on the Property?
11 Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the • •• -rty Under Recorded Contract
for at Least One(1)Year before Clawri 'g redit")
PA Yes El No
Address of Contract Seller (number and street, city. state. and ZIP code) Fir Property in Question.
rAl Real Property ❑ Mobile Home (1C 6-1.1-7)
Taxing Distnct___CD O G . Key Number J Legal Description Record Number Page Number 1
4 1 V 1-too_ 000•0 -006•
-_- .�
I
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 ri 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 Poor to the Year Taxes are First Due& Payable? es ❑ No
$ -
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
� -Signature of Applicant ---- - - - - - - --- - ----
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Date (month. day, yea
Address of Applican (number and street. city. state. and ZIP code)
" � Date (month, day, year)
S 1 1 si.D.E
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Sig ature of Authorized Representative `�� 6D %
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-- --t- - - — - - - - --- 1
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1 Address of Authorized Representative (number and street. city. state. and IfP code)
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tillirli)oli .
---T_N _ _ . i Date (mo th, day, ar) -G fr
Sranature of County udrt rN \tad
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DISTRIBUTION: Original - County Auditor: File-Stamped Copy - Taxpayer