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d * �"'4 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS Pdao
„,, 1 State Form 43708(R19/7-25)
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• ,s,. Prescribed by the Department of Local Government Finance C-2 I D.Sat-T-171•0f .
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 calendar year in
which the properly taxes are first due and payable.
See reverse side for additional instructions and qualifications.
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Type of Benefit Requested (Please check all apply) [�l�,p
_� ver 65 Credit ver 65 C/iirairc B e Credit
Cme of Applicant (ow r or tort a yer), Telephone Number Em ddress �U
ilt- 4 i i Pt� � - ��
p • egal or Equitable Owner? If No, What is Applicant's Exact Share or Interest? If Owne tan r- enant in Com dicate with Whom
cd-el<s
vwi�,❑No AV .
If Name on Record is Different than Applicant, Indicate Below Do All Joint Tenants or Tenatrti i ;mmon Reside on the Property?
es ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One(1)Year before Claiming Credi
k . . PS
. M 'es ❑ No
Address of Contract Seller (number and street, city, state. and ZIP code) Is the Property in Question
eal Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
P63[0\t-cL _ cam'cm - -,-. 1-(co-oco • cao .1
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 es 0 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 tot ar Ta es are First Due 8 Payable? EileS 0 No
Ei, plicant's Date of 'rth (month, day. year) i LQ (1) If Filed by a Surviving, Unmarred Spouse,What Was the Spouse's Age at the Time of Death'
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Source of Income Amount of Income
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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! � f
may not exceed (1) $60,000 for individuals who filed a single return, (2) $70,000 fora 0 scD,...\ , 2 c
individuals who filed a joint return, or(3) $/0.000 fur individuals and all others that
share ownership as joint tenants or tenants in common For the Over 65 Circuit Breaker Credit, AG!may not exceed' (1) $60,000 for individuals who filed a single c. $ 1 .1
1.....‘a
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 $
IiWe certify under penalty of perjury that the above and foregoing information is true and correct.
Si atur of Applicant Date (month, day, year)
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A dress of AO. nt (number and sire . city, state, and ZIP cod
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month, day, ear)
k-i 2 a LA • 0 \ . irriVilih al-1\-0 V__Ci_ v..a. 1 0 aiciLifa,_
Signature of Authorized Representative Date ( y y
•
Address of Authorized Representative (number and street. city. state, and ZIP code)
Signature of County Auditor ' Date (month, day, year)
1
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DISTRIBUTION: Original — County Auditor; File-Stamped Copy - Taxpayer