Age_Bruce APPLICATION FOR SENIOR CITIZEN
���`�'��,4 COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
\. ., �f State Form 43708 (R19/7-25) Sb 11 02/C -
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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
+- .
I Type of Benefit Requested (Please check,all that apply)
f
Over 65 Credit , Over 65 Circuit Breaker Credit
r'an�e of Applicant (owner' or con ct b er) ep one Number mil Address
Is Applicant the Sofre Legal or Ecgtable Owner? / If No, What is Applicant's Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
.
Yes ❑ No
If Name on Rec rd is Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in C m Reside on the Property?
Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Prope Under Recorded Contract
for at Least One(1)Year before Claimi edit?
Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code) Is the roperty in Question:
Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District Key Number Legal Description Record Number Page Number
2 - ) -) 3 _ o2rOOd -ci - -- 02
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
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,
$
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant Date (month, day, year)
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) 'Addret ( mber and street, city, state, and IP co e)
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Signature of Authorized Representative ) Date (month, dr(ear) ��
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Address of Authorized Representative (number and street, city, state, and ZiP code) s0 4
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Signature of County Audit r Date (m nth, day,��ear) .q,--) 1D ...., 7.4
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DISTRIBUTION: Original - County Auditor; File-Stamped Copy - Taxpayer