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P4 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
\. ;; State Form 43708 (R19 / 7-25)
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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 auditor or postmarked by January 15 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 cheek all that apply)
Over 65 Credit Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract kiyer)
- .
Is Applicant t e -•al or Equitable Owner? If No, What is Applicant's Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
1 Yes ❑ No
If Name o 'eco • is Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in C• mon : . ide on the Property?
Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the 'rope ' Under Recorded Contract
for at Least One(1)Year before Claimi . Cr:,.* :
11 Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code) Is the Property in Question:
Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District IAD11
Key Number I Legal Description Record Number Page Number
(02.,.E ..... c7
2_ , - 1\ - i-2_ -'0 -0C' ( - 1 6 - 02-1S. •
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 Prior to the Year Taxes are First Due & Payable? ❑Yes ❑ No
If Filed by a Surviving, Unmamed Spouse, What Was the Spouse's Age at the Time of Death?
Source of Income Amount of Income
Adjusted Gross Income (AGI) of applicant, applicant and spouse, or applicant
and joint tenants or tenants in common, as applicable (For Over 65 Credit, AG! $
may not exceed.' (1) $60.000 for individuals who filed a single return; (2) $70,000 for '
return, or(2) $70,000 for individuals who filed a joint return with the individual's
spouse.)(Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted.]See reverse for details. TOTAL $
I/We certify under penalty of perjury that the above and foregoing information is true and rrec
Signature of Applicant Date (month, day, year)
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Address of Applicant (number and street, city, state, and ZIP code) 2025 ) `I
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Signature of Authorized Representative
GIBSON CO ''• Tv 4LIDITOR
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Address of Authorized Representative (number and street, city, state, and ZiP code)
1
Signature of County Auditor Date (mont , day, y ar)
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DISTRIBUTION: Original — County Auditor; File-Stamped Copy — Taxpayer