HomeMy WebLinkAboutAge_Basham 4~` "'1•n. APPLICATION FOR SENIOR CITIZEN COUNTY FTOWNSHIP YEAR
;i - 7 = PROPERTY TAX BENEFITS i
5. ,,, State Form 43708 IR19 ?/S 2a1 t�7-25) � I
•
'41� Prescribed by the Department of Local Government Finance l 1
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. VI — 12 — 2-\ ----
, 99-06
_ __,
Type of Benefit Requested (Please check a that apply)
ver 65 Credit Over 65 Circuit Breaker Credit
e of Applicant (owner tr t b er) Telephone Number Emai Address
CN.r)1 Lk • COkC\.0/ . ( )
Is scant the Sole 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 Ell No _ _
If Name on �c d is Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in C. on Reside on the Property?
PA Yes ❑ No
Name of Contract Seller Has Applicant Owned or Bought the • o.•rty Under Recorded Contract
for at Least One(1)Year before Claimn' C -dst'
11 Yes ❑ No
Address of Contract Seller (number and street, city. state. and ZIP code) Is the Property in Question
Real Property ❑ Mobile Home (/C 6-1.1-7)
Taxing District i Key Number/ Legal Description _ Record Number Page Number
r25(K' r- f \-\ vE\ 1_2,6 - 17 -\s voi - 000 . 1060 „
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 ;I 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? r Yes ❑ No
Applicant's Date of Birth (mo th. day, year) If Red by a Surviving, Unmarred Spouse What Wa the Spouses Age at the Time of Death'
Sgl S S
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, AGI ` $
may not exceed (1) $60,000 for individuals who filed a single return. (2) $70,000 for \) .
individuals who filed a joint return,or(3) $70,000 for individuals and all others that :__ __C2Cd_AZI--
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
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 e c-rtify under penalty of perjury that the above and foregoing information is true and correct.
Signatu - of 9ppl � Date (month. day, ye
ep
.y Address of Applicant (number and street, city, state, and ZIP code)
\ WI s 1%\N-ne_ si r
0,6, .
<-0,..26,1
Signature of Authorized Representative , •
4 ,-• - h. day, year)
Obc
Address of Authorized Representative (number and street. city, state, and ZIP code) ,9G
o,
Signature of ounty Au itor ciD—: M — Date ( onlh, da . ye T9
2 IND__.2,-.6.
DISTRIBUTION: Original - County Auditor: File-Stamped Copy - Taxpayer