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HomeMy WebLinkAboutAge_Stevens 4 APPLICATION FOR SENIOR CITIZEN A t COUNTY TOWNSHIP YEAR 11 . i=, PROPERTY TAX BENEFITS ' ,,, Q State Form 43708(R19/ 7-25) _ (Ir- � ii Prescribed by the Departrnent of Local Government Finance bSO f� �1J 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 all that apply) LJ ver 65 Credit ❑t fiver 65 Circuit Breaker Credit Name of Applicant (owner or contract buyer) Telephone Number Email Address �r l # Paine lee,\)ems, • ( 2 ) I q( - � . - is Applicant the Sole Legal or Equitable Owner's If No, What is Applicant's Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common, Indicate with Whom 1 SQ L T El No 1Z2 on Record is Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property? ❑�'es O No Name of Contract Seller Has Applt Owned or Bought the Property Under Recorded Contract for at Least One(1)Year before Claiming Credrr){ QYes ❑ No Address of Contract Seller (number and street, dry, state, and ZIP code) Is the Pr in Question: Real Property ❑ Mobile Home (IC 6_1 1-7) Tig District Key Number/Legal Description Record Number Page Number ov_YicALce_ Ocak,kik . cQL DA -a-_-‘ - ilot__I . 000 . - cli, - 0431 Did Applicant qualify for the homestead standard deduction in the preceding year(or was applicant marred at the time of death to /� a deceased spouse who qualified for a homestead standard deduction for the individuals homestead property in the immediately 1Yes 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 to the Year Taxes are First Due 8 Payable? © s 0 No Applicant's Date of Both (month, day, year) If Fled by a Survmng, Unmarred Spouse.What Was the Spouse's Age at the Time of Death? T - \-t 1-\-1 " F - 1 CA 1 j LA 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 $ may not exceed (1) $60,000 for individuals who lied a single return, (2) $70,000 for \ L { ndrvrduals who filed aprnt return, or(3) $70,000 for individuals and al others that0 �L' share ownership as pert tenants or tenants in common. For the Over 65 Circuit Breaker Credit, AGI may not exceed: (1)$60,000 for ndrviduals who filed a single Q V a S $ LC 7 q01)return, or(2)$70,000 for individuals who filled a pint return with the mdividuaJs spouse.)(Beguiling with Pay 27, r1artrie amounts for the Circuit Breaker Credit are annually adjusted j See reverse for details. TOTAL $ r I/We certify under penalty of perjury that the above and foregoing information is true and correct_ Signature of Applicant Date (month. day, year) '71c-- C., "" \ a - U , Address of App a nt (n tier a street,etty, state, and ZIP code) \ \I) Po V & s___ , L`'`1 Signature of Authorized Representative f Date (month, day, year) v Address of Authorized Representative (number and street, city, state, and ZIP code) Signature of County Auditor Date (month, day, year) \if\c\, - _ki- 40L. 01 . OiLAAL 1 rqUi _ �— , 6— LED MAR 1 0 202 a 3D. DISTRIBUTION: Original County Auditor; File-Stamped Copy - Taxpayer J/1'�'.I:k'i d) �y����.� W. GIBSON COUNTY AUDITOR