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04 R,., APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
'� �1: PROPERTY TAX BENEFITS .
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State Form 43708 (R19 / 7 25) JO
CA
• 'CID Prescnbed 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. V-2_ --- L -- ?'2 1(gG `
Type of Benefit Requested (Please heck ll that apply)
_ Over 65 Credit Over 65 Circuit Breaker Credit
Name of A. licant (owner or contr t b yer) Telephone Number m I Address
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'�'.p• the So 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 c rd is Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in COMA on Reside on the Property?
_ Al Yes ElNo
Name of Contract Seller Has Applicant Owned or Bought t r •rop•rty Under Recorded Contract
for at Least One(1)Year before Claiming redd7
es ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code) Is th Property in Question
eal Property ❑ Mobile Home (/C 6-1.1-7)
Taxing District Key Number I Legal Description Record Number 1 Page Number
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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 Poor to the Year Taxes are First Due& Payable? Yes ❑ No
Applicant's Date of Birth (month. day, year) If Filed by a Surviving,Unmarried Spouse, t Wa the Spouse's Age at the Time of Death?
Ca) ' 10)11l 5-4 a - \ 1t 6 2
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 �� $ tk'���111
may not exceed: (1) $60,000 for individuals who filed a single return; (2) $70,000 for0 /
individuals who filed a joint return: or(3) $70.000 for individuals and all others That — 1
share ownership as joint tenants or tenants in common. For the Over 65 Circuit (C) 2--t-\ $ 2_9
Breaker Credit, AGI may not exceed: (1) $60,000 for individuals who filed a single C\
return, or(2) $70.000 for individuals who filed a joint return with the individual's _ 1, .4t) {
spouse.)(Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted]See reverse for details. I TOTAL $
1 —
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
FIL D
Signatur of Applicant/\c
Date (month, day, year)
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Addre of scant (number and street. city. st , and ZIP code)
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Signature of Authorized Representative Date (mo I ay; year)
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GIS�ON COUNTY AUDITOR
Address of Authorized Representative (number and street. city. state, and ZIP code)
Signature of County Auditor Date ( onth, day year)
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DISTRIBUTION: Original - County Auditor; File-Stamped Copy - Taxpayer