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` ""'4 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
d1 PROPERTY TAX BENEFITS ,
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State Form 43706 (R19 17 25) L.C.V.1
'•i• Prescribed by the Department of Local Government Finance
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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 Dafe: 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.
1 Type of Benefit Requested (Please check all that apply)
L6ver 65 Credit _ Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer) Telephone Number Email Address
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Is Applicant the Sole Legal or Equitable Owner? If No, What is Applicants Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
Yes ❑No j _ ,
If Name on Record is Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in Common 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 Cre
Yes ❑ No
Address of Contract Seller (number and street. city, state, and ZIP code) Is the Pro rty in Question
Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing Dlstnct Key Number / Legal Description Record Number Page Number
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 liaes ❑ 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? es ❑ No
Applicant's Date of Birth (month. day, year) If Filed by a Surviving,Unmarried Spouse,What Was the Spouse's Age at the Time of Death?
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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, AG! $
may not exceed: (1) $60.000 for individuals who filed a single return: (2) $70,000 for bor__,
�individuals who filed a joint return;or(3) $70,000 for individuals and all others that - -- -
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 C1
return, or(2) $70.000 for individuals who filed a joint return with the rndrvrdual's 1
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 Applican Dale (month. day, year)
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A es pplicant (number an eet. city, state, and ZiP code)
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Signature of Authorized Representative Date (mor% . year) 65
Address of Authorized Representative (number and street, city, state. and ZIP code) CI
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Signature of County Auditor Date (month, day, yea l X'�
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DISTRIBUTION: Original - County Auditor; File-Stamped Copy - Taxpayer k