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�, I APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
r- , PROPERTY TAX BENEFITS
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_. State Form 43708(R 19 i 7 25) (1.--)
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' • Prescnbed by the Department of Local Government Finance iA. ( - ' c' 1 lc
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9
Instructions To be bled 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)
ladier 65 Credit 1:15 Circuit Breaker Credit
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Name of Applicant (owner or contract buyer) Telephone Number Email Address _.,
rn. ( 01- h r<�10{� la.) LOUq -tea Lk--1
Is Applicant the Sole Legal or Equitabl r? If No. What is Applicants Exact Share or Interests If Owned with Joint Tenant or Tenant in Common. Indicate with Whom
o-Yes ❑ No
If Name on Record rs Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
[des ❑ No
Name of Contract Seller Has Applicant Owned cx Bought the Property Under Recorded Contract
for at Least One(1)Year before Claiming Credo
es ❑ No
Address of Contract Seller (number and street_ city, stare, and ZIP code) Is the Property in Question
Et eat Property ❑Mobile Home (/C 6-1 1-7)
Taxing Distnct Key Number/Legal Descnption Record Number Page Number
P02,, ,Nc.e -Icer-N _ au__ \ - L_ - ]O3 -- 0 0 .-1 ``1 D - C r3 ,
Did Applicant qualify for the homestead standard deduction in the preceding year (or was applicant mamed 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 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? Yes ❑ 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?
NA — 11 r-[ .1 _0 0 —J' < - ar -1 S 8
1 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 (f-or Over 65 Credit, AGI + DOLA $may not exceed (1) S60,000 for individuals who fled a single return, (2) S70,000 forC)-i
ndnoduals who filed a joint return, or(3) S70.000 for rxhvKluals and all others that
share ownership as joint tenants or tenants in common For the Over 65 Crcuet
Breaker Credit, AGI may not exceed (1) 560,000 for ridrvxivals who hied a single 0 Dr" $ L,--(return, or(2)S70,000 for rrd+vrduals who filed a pint return with the ridn*af's , - .>_ - I --
spouse-)[Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted J See reverse for details. TOTAL S --
IIWe certify under penalty of perjury that the abo a and foregoing inlormatlo is true and c
rect
thk o l / 0 m n earSignal a of Applicant Date (month, day, year)
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Address of Applica (numbe1QL
d street, city, state, and ZIP
Sao . ��. tom.
Signature of Authorized Representative Date (month, day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code) FILED
Signature of County Auditor Date (month, day, year)
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DISTRIBUTION: Original - County Auditor; File-Stamped Copy - Taxpayer GIBBON COUNTY AUDITOR