HomeMy WebLinkAboutAge_Kates 's'-s'"' APPLICATION FOR SENIOR CITIZEN
COUNTY TOWNSHIP YEAR
iiir �'" PROPERTY TAX BENEFITS
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State Form 43 708(R19 l 7-25) ) 0 11—\‘', P2--(9111
'• Finance Prescribed by the Department of Local Government 0()
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1 1-35-9.
Instructions To be filed in person or by marl 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 properly taxes are first due and payable.
See reverse side for additional instructions and qualiflcati k ec
Type of Benefit Requested (Please the all that apply)
le Over 65 Cr Over 65 Circuit Breaker Credit
of Applicant(owner or contr • b.i •r) Telephone Number • Address
\ cc 1 11( \ . ( )
Is Applicant ? 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
if Name on Rrcor is Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in • • Reside on the Property?
E Yes ❑No
Name of Contract Seiler Has Applicant Owned or Bought the ••.• Under Recorded Contract
br at Least One(1)Year before • • •I.
El Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZiP code) Is the Property in Question.
Real Property ❑ Mobile Home(1C 6-1.1-7)
Taxing Distnct Key Number/Legal Description ff \ Record Number Page Number
(r)0\ - - a 1 . 2 --W 16--30 0 -oCP . oo l .
DidApplicant qualifyfor the homestead standard deductbn in the �\ r
preceding year (or was applicant marred 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 Yes ❑ No
preceding calendar year)and does Applicant quality 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? Yes ❑ No
icant's Deft If Bi h (month, day, year) It Filed by a Surviving, Unmarried Spouse, Was Spouse's Age at the Timed Death?
3 S 1 .
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 )02- - S 1 -L6 may not exceed (1) S60,000 for irdiwduals who fried a single return, (2)$70,000 for
mdmduals who filed a lcxnt return;or(3) S70.000 for individuals and al 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 fried a srigler-) 4° 14 S 3 S Li
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4_
return, or 2 S70 000 for indrv+duals who filed a t return with the ndrviduars
spouse_)(Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted.)See reverse for details. TOTAL S
IfWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant Date (month. da ar)
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Address of Ap licant (number and street, stale, and ZIP code)
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Signature of Authorized Representative Date (month, day, year) 0
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Address of Authorized Representative (number and street, city, state, and ZIP code) C rvr."1.4
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Signature of County Auditor D (month, day, year) iv
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DISTRIBUTION: Onginal - County Auditor, File-Stamped Copy- Taxpayer