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APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR 7
!� PROPERTY TAX BENEFITS
• State Form 43708(R19 / 7-25) Co.
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'llio• Prescnbed by the Department of Local Government Finance • --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.
Type of Benefit Requested (Please check that apply)
Il Over 65 Credit ae<65 Circuit Breaker Credit
Name of Applicant (owner or contras�uyer}�c Telephone Number Email Address
a d.\)-, s .Aw }c�c(>�C��L i" (g i a 'L-QUILA — Q. t CH .
Is Applicant 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 ❑No
If Name on Record is Different than Applicant, Indicate Below �Do All Joint Tenants or Tenants in Common Reside on the Property?
_ _ — li,ieS ❑ No
Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1)Year before Claiming Credit'?
UK; ❑ 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 astnct Key Number I Legal Description Record Number Page Number
IINIM4-ACC\e-4Tha -- C— Q--(0- DS—e%)0 -co" 1--i0- 0 t ._
Did Applicant qualif r the home to 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 ❑ 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 faxes are First Due & Payable? I ' 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?
b - 4,, 5., • -- ( iS.11y .I � 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! $ LA
may not exceed (1) $60,000 for individuals who filed a single return. (2) $70,000 for a -
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 $ t ,
Breaker Credit, AGI may not exceed: (1) $60,000 for individuals who filed a single
filed a joint return with the individual's (r'w 1
return: or(2) $70,000 for individuals who —.
spouse.)[Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted.]See reverse for details. TOTAL $
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I/We certify under penalty of perjury that the above a d foregoing i formati n is true and correct.
~Si ur of Applicant Date (month. day. year)
/ X ' CD— 11 '' U31 •
ddress of Applicant (number and sties . a , state, and Zi co e) •
q6ict Date (month, day. year)
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ignature of Authorized Representative
Address of Authorized Representative (number and street, city, state. and ZiP code)
FILED
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Signature of County Auditor J Date (month, day, year)
Q_ \ ` I I - .FEB 11 2026-_
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m ed Co Taxpayer DITOR
DISTRIBUTION: Original — County Auditor; File Sta C'Y — GIBSON COUNTY AU