Age_Hyatt ,-.0*'s. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR ;li- • \ PROPERTY TAX BENEFITS rye '!` State Form 43708(R161 1-23) S 0() 02 2J 3 Z.3 .'e1'. Prescribed by the Department of Local Government Finance Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. 0 \ tjf INSTRUCTIONS: To be filed in person or by mail with the county auditor of the county where th pr per' r located. V\VII Filing Date: Form must be completed and signed by December 31 and filed with the county auditor or po rked by the following January 5 of the calendar year in which the property taxes are first due and payable. ff�r. See reverse side for additional instructions and qualifications. 0�O 1 y ._) I Type of Benefit Requested(Please che- all that apply) - Over 65 Deduction from Assessed Valuation Over 65 CircuitBreaker Credit t of Applicant(o.x, r r contra t b er) Telephone Number E ail Address "Nr 0\ ($IZ ) 6 44 —3)-1-13. Is Applicant the Sole Legal r quitable 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 than Applicant,Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property? Yes Li No Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract for at Least One(1 i Year before Claiming Deduction? _ Yes _ No Address of Contract Seller(number and street,city.state.and ZIP code) Is Property in Question: Real Property Mobile Home(1C 6-1.1-7) Taxing District Key Number i Legal Description Record Number Page Number 023 • a—M 01— ©<<-Oc3.LIS -02_g . Does Applicant e de on Property? Assessed value of the property as of current year assessment date(May not exceed 3240,000 for Over 65 Deduction or _ 5199,999(counting just the homestead site)for the Over 65 Circuit Breaker Credit received before January 1.2020. and 5199.999(al Yes - No Indiana real property)for the Over 65 Circuit Breaker Credit initially applied for after December 31,2019.)See reverse for details. Is the Applicant 5 ar of Age or More on Decem r 31 the Year Prior Applicant's toe of B rth month,day,year) If Filed by a Surviving.Unmarred Spouse.What Was the to the Year T xes are first Due 8 Payable? Yes No 1 9 .{- 0 _ Spouse's Age at the Time of Death? Adjusted Gross Income(AGI)of applicant,appti nt d spouse,or applicant 1 ' Source of Income Amount of Income and joint tenants or tenants in common,as app!cable or Over 65 Deduction,AGi may S /t t not exceed:(1)S30,000 forindividuals who filed a single return;(2)540,000 for individuals _ ( 1�./ : who filed a joint return,or(3)540.000 for individuals and all others that share ownership as t �1 t joint tenants or tenants in common,For the Over 65 Circuit Breaker Credit,AGI may not i S exceed.(1)S30,000 for individuals who filed a single return;or(2)S40,000 for individuals who filed a joint return with the individual's spouse.)See reverse for details. TOTAL S Have You Filed for An Oth r Deductions? If Y , i l Deductions? Yes ❑No Have You Filed for De 'on in Any Other C unt•? If Yes.W at County ❑Yes o I/We certify under penalty of perjury t at the bove and foregoing information is true and correct. i Signature of Applicant I Date(mo th,day., ar) Address of Applic (number and street,c.y.state.and 93 code) Signature of Authorized Representative Date(month.day.year) _ _ . Address of Authorized Representative(number and street,city,state.and ZIP code) II Si.cnature of County Auditor Date(month, day.year) iFILED (\..S CI) • 0 C T 2 4 2023 D15T 1 : Original-County Auditor; File-Stamped Copy- Taxpa ''''''" ..'" `-..., ' �r=r�.u'r:1-' ,.:,IFiSON COUNTY AUDITOR