Age_Deal t^•r•4 APPLICATION FOR SENIOR CITIZEN
��i1y COUNTY TOWNSHIP YEAR
�, .:. _ a PROPERTY TAX BENEFITS
x' i State Form 43708(R15/1-20)
Prescribed by the Department of Local Government Finance .5V'el OZ - vvn lry
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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 Date: Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the following
January 5 of the calendar year in which the property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Type of benefit requested(Please check all that apply.)
❑Over 65 Deduction from Assessed Valuation ❑Over 65 Circuit Breaker Credit
Name of applicant(owner or contract buyer)
1-0ann°t •
Is applicant the sole legal or equitable odner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
❑Yes El]No
If name on record is different than that of applicant,indicate below. I Do all joint tenants or tenants in common reside on the property?
Ell Yes [1]No
Name of contract seller Has applicant owned or been buying the property under recorded contract for
at least one(1)year before claiming deduction?
❑Yes CI No
Address of contract seller(number and street,city,state,and ZIP code) Is ' property in question:
eat property ❑Mobile home(IC 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
Does applicant reside on op y? Assessed value of the property as of current year assessment date(May not exceed$200,000 for Over 65 Deduction or$199,999
Yes ❑No [counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1,2020,and$199,999[all Indiana real
l property]for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details.
Is the applicant 65 years o ag or more on Dece .er .1 of the year Applicant's date of birth(month,day,year) If filed by a surviving,unmarried spouse,what was
prior to the year taxes ar first d and payable? Ili Yes ❑No — 3-2��3 1 the spouse's age at the time of death?
Adjusted Gross Income(AGI)of applicant,ap%ican and spouse,or applicant Source of Income Amount of Income
and joint tenants or tenants in common,as applicable(For Over 65 Deduction,
AG!may not exceed:(1)$30,000 for individuals who filed a single return;(2) -2--0 2 I. $ , 9(1 c
S40,000 for individuals who filed a joint return;or(3)S40,000 for individuals and all 'r1 L
others that share ownership as joint tenants or tenants in common.For the Over 65 C, 2 2 Z
$ I S�--0
Circuit Breaker Credit,AGI may not exceed:(1)S30,000 for individuals who filed a
single return;or(2)$40,000 for individuals wh joint return with the
individual's spouse.)See reverse for detail TOTAL $
Have you filed for any other de+uc'•ns? f e hat deductions'?
E Yes J
Have you filed for deductions' a othe c ? If Yes, hat coin -
❑Yes o
I/We certify under penalty of perjury tha the above and foregoing i�11��fq�ma$o5 izOa3and correct.
Signature of applicant DaIn ear)
Address pplf nt ( m r and street, state,and ZIP code) J r'� " AUU
3 2 03SON COUNTY
ign a of authorized representative Date(month,day,year)
Address of authorized rep/ enta ive (number and street,city,state,and ZIP code)
SignaturepfCou Au ' Date10 to year)
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