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4 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
414 - �:' PROPERTY TAX BENEFITS _
State Form 43708 (R1917-25) S0 n O2_ 02,S--
4... Prescribed by the Department of Local Government Finance I
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.
Over 65 Credit ver 65 Circuit Breaker Credit
Name of Applicant (owner or contra b r) Telephone Number _mat Address
\` L1'1�'1( k . ( )
1
Is Applicant o Legal 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
Yes ❑No
If Name on R cor 's Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in C. mon Reside on the Property?
PI Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the ' ope ' Under Recorded Contract
for at Least One(1)Year before Claimi . ► edit'?
VA Yes ❑ No
Address of Contract Seller (number and street, city. state, and ZIP code) Is th Property in Question.
Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing Dist ' t Key Number/ Legal Description Record Number Page Number
2t-- 0—\ 21-100-001 sE7k1 -0 A ,
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?
and spouse, or applicant --
and joint tenants or tenants in common, as applicable (For Over 65 Credit, AGI I � � �� $ � � _.emn�
may not exceed: (1) $60,000 for individuals who filed a single return; (2) $70,000 for �, u(
individuals who filed a joint return: or(3) $70.000 for individuals and all others that I
share ownership as joint tenants or tenants in common. For the Over 65 Circuit
Breaker Credit, AGI may not exceed: (1) $60,000 for individuals who filed a single -)/-0' 2� $ 29 S'"IR
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 correct.
Signature of A 'cant Date (month, day, year)
, / .
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Address of Applicant (nut r and street, city, state, and ZiP code)
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Signature of of Authonzed Representatile ) Date (month, day, year)
Address of Authorized Representative (number and street, city, st e, n Zl code)
Signature of Coun Auditor Date (m nth, day, yearrr))�
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VI S lAN U b
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DISTRIBUTION: Original — County Auditor; File-Stamped — yY AUDITOR
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