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HomeMy WebLinkAboutAge_McEllhiney (6) Ltit. am ? APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR PROPERTY TAX BENEFITS State Form 43708(R19/ 7-25) ` - ` ,r '•• Prescribed 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 it'rth the county auditor or postmarked by January 15 of the calendar year in which the properly taxes are first due and payable. See reverse side for additional instructions and qualifications Type of Benefit Requested (Please check all that apply) wer 65 Credit Q©trer 65 Circuit Breaker Credit Name of Applicant (owner or contract buyer) Telephone Number Email Address _ t\Qrk A . - �� Q . m 11h 1 c� om Is Applicant the Sole Legal or Equitable Owf 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/ El Yes El No Name of Contract Seller Has Applicant Owned or Bought the Property Under Recorded Contract brat Least One(1)Year before Clam ❑No Address of Contract Seller (number and street, city, state, and ZIP code) Is the Property in Question. 0'Real Property ❑ Motile Home(IC 6-1-1-7) Taxing Distnct Key Number/Legal Description Record Number Page Number PiaiKiL4 _ i (0 - 1 -C)ct - - cc Did Applicant qualify for the homestead standard deduction in the preceding year (or was applicant named at the time of death to ��� a deceased spouse who qualified for a homestead standard deduction for the individuals homestead property in the immediately Dn'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 Pnor to the Year Taxes are First Due& Payable? Yes El No Applicant's Date of Birth(month, day, year) If Filed by a Survnnng, Unmamed Spouse.What Was the Spouse's Age at the Time of Death? 1D - cO . 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!mayQ not exceed (1) 560,000 for individuals who filed a single return, (2) 570,000 for individuals who bled a joint return, or(3) S70.090 for ndividuals and a/others that share ownership as joint tenants or tenants in common. For the Over 65 Circuit Breaker Credit,AG!may not exceed (1)S60.000 for individuals who filed a sn� ne SL.\ aL\ return, or(2)570,000 for individuals who fled a pint return with the ridividuafsL„J t `� spouse.)(Beginring with Pay 27, income amounts for the Circuit Breaker Credit are annually adjusted.]See reverse for details. TOTAL S - --- I/We certify under penalty of perjury that the above and foregoing information is true and correct. Signature of Applicant Date (montn day, year) 1i1, a- , 711 LQ Address of Applicant (number and street, city, state, and ZIP ) 3 lC S. . ) rN c % `.-k U`1 d . Signature of Authorized Representative r Date (month, day, year) Address of Authorized Representative (number and street, city, state, and ZIP code) Ig I LED Signature of County Auditor )ifY\ Date (month, day, ) \LA._ f- 5 Zozs „(Th,e9 DISTRIBUTION: Onginal - County Auditor File-Stamped Copy - Taxpayer (722„,/.. GIBSON COUNTY AUDITOR