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4,,-` 'T'- . APPLICATION FOR SENIOR CITIZEN
COUNTY TOWNSHIP YEAR
(a: ' ) PROPERTY TAX BENEFITS '
\ /� State Form 43708 (R19/ 7-25) I1I2-
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 where the property is located.
Filing Date: Form must be completed, signed. and filed with the county
Over 65 Credit Over 65 Circuit Breaker Credit
N me of Applica t (owner or contr t bu er)
Owned with Joint Tenant or Tenant in Common, Indicate with Whom
Yes ❑ No
If Name on ecor is Different than Applicant, Indicate Below : Do All Joint Tenants or Tenants in Common Reside on the Property?
ill Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the •r••; Under Recorded Contract
for at Least One (1)Year before Claimin edit?
Yes ❑ No
Address of Contract Seller (number and street. city. state, and ZIP code) Is th Property in Question
Real Property ❑ Mobile Home (IC 6-1. 1-7)
Taxing District l Key Number / Legal Description 3 Record Number Page Number
02S T - n 26 -1Z.-1S - 0 I - oCA -off
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?
Is 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
$
IIWe certify under penalty of perjury that the above and foregoing information is true and correct.
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r of AppDateo , dayf Applica (number and eet, car, state, and lP code)
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Rio, ,, _ LI4-L �qK) 1c 1� N j
Signature of Authonzed Representatrvee Date 'nth. day. year) 20
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Address of Authorized Representative (number and street, city, state. and ZIP code) 80M �G:y
CpOIV ' ,1.
Signature of County Auditor Date (month, day. year) AUb/O
t i rS CDC 1 c 2— . R
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DISTRIBUTION: Original — County Auditor: File-Stamped Copy — Taxpayer