Age_Crain 't"q APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR _
r PROPERTY TAX BENEFITS
t State Form 43708(R13/4-15) /`x\sQY\ it _ 1 lot
ii-- Prescribed by the Department of Local Government Finance l/Jlt y _ ' '1'N�I�w`I�1"wl
I I
File Mark
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 Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or manufactured homes not assessed as real property:During the twelve(12)months
before March 31 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Type of benefit request (p ase check all that apply)
ver 65 Deduction from Assessed Valuation ❑ Over 65 Circuit Breaker Credit
Name of applicant(ov er or ntract buyer)
f
Is applicant t e 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 n that of 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 been buying in theproperty under recorded
contract for at least one(1)year before claiming deduction?
❑ Yes ❑ No
Address of contract seller(number and street,city,state,end ZIP code) Is the property in question:
,(Real property ❑ Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Recorr number Page number
Does applicant reside on property? Assessed value of the property as of current year assessment date(may not exceed
$182,430 for Over 65 Deduction or S159,999(counting just the homestead site)for the Over
❑ No 65 Circuit Breaker Credit.)
YesSee reverse for details.
Is the applicant 65 years of age or more on Deco ber 1 of the year Applicant's date of birth(month,day year) If filed by a surviving,unmarried spouse,what
prior to the year taxes are first due and payable? was the spouse's age at the time of death?
' Yes ❑ No FebAdjusted gross income of applicant, applicant and spouse, or
exceed S30,000 for individuals or S40,000 for married couples.). $
See reverse for details. TOTAL I $ 0.00
Have you filed for any other deductions? XYes
If Yes,what deductions?
❑ No LED
Have you fled for deductions in any other county? If Yes,what county?
ID ,�(Yes I�1\No APR 17 2019
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
ignature of applicant Address of applicant (number and streetela¢�, � 0.IdAUU(TOR
l S ticiat d c t'`—f'1l.e�nc.h
ig ure of authoriz representative Address of authorized representative (number and street,city,state,and ZIP code)