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...,. ""•4 APPLICATION FOR SENIOR CITIZEN i COUNTY i TOWNSHIP YEAR ,
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¢; .� 4 PROPERTY TAX BENEFITS r A
' State Form 43708 (R19 / 7-25) I S�tn f C rLe4-
• "7-02 s
WO Prescribed by the Department of Local Government -mantic -
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
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Type of Benefit Requested (Please c ec all that apply)
Over 65 Credit Over 65 Circuit Breaker Credit
N e of Applicant (owner or contr I uyer) Telephone Number ail Address
1/(4t0\ 134Nic -
is Applicant th Sol 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
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Yes ❑No — - — —�
If Name on R co d is Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
RI Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the .'•' Under Recorded Contract
for at Least One (1)Year before Claims edit?
Yes ❑ No
Address of Contract Seller (number and street, city, state. and ZIP code) I Is t P rty in Question
I Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing D tnct Number/Legal Description Record Number Page Number 1
0 rn - -Tuasf `26'-- 12 r 2%0 MO. &r V2- — .
Did Applicant qualify for the homestead itandard 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?
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Appiican' Date (month. day. year)
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Address r Applicant (number and street, city, state, and ZIP code) �( _ u, --(z.. -.D . ___ .
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VI- Dat th. day year I _
Signature of Authorized Representative �1 L�
Address of Authonzed Representative (number and street, city, state. and ZIP code) ✓CO Q 4e7
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Signature of C unty ditor
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1 1 ( 5 tID"&-•, '
DISTRIBUTION: Original - County Auditor: File-Stamped Copy - Taxpayer