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4 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
{ PROPERTY TAX BENEFITS
".- 1 State Form 43708(R19 1 7-25) (9b`A - G' �2_‘
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•,...--- 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 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 c ‘ 2:-C
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Type of Benefit Requested (Please heck all that apply)
Over 65 Credit Over 65 Circuit Breaker Credit
of Applicant (owner or cx ntr fryer) Telephone Number address
is Applicant pe • - 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
PA Yes EI No
if Name on •ec• • is Deferent than Applicant, Indicate Below Do All Joint Tenants or Tenants in CQmmgin Reside on the Property?
111 Yes 0 No
Name of Contract Seiler Has Applicant Owned or Bought the • if Under Recorded Contract
for at Least One(1)Year before gaming S •.
■ es ❑No
Address of Contract Seller (number and street, city, state, and ZIP code) Is eproperty in Question
Real Property Mollie Home(IC 6-1.1-7)
-Taxing Distnct. Key I Legal Description Record Number Page Number
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Did Applicant qualify for the homestead 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 Yes 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& Payable? ❑ No
Applicant's Date of (►rftt, day, year) If Filed by a Surviving. Unearned Spor fine
pinn
e. the Spouse's Age at the Te of Death?
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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 2 4 s ,,--may not exceed (1) $60,000 for individuals who filed a single return::(2) S70,000 for , --� �;
ndividuals who filed a joint return, or(3) $70,000 for individuals and air others that •
share ownership as jorit tenants or tenants in common For the Over 65 Circuit
Breaker Credit, AGI may not exceed: (1) $60,000 for individuals who filed a single 2 S ..Q 0
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return;or(2) $70,000 for individuals who filed a joint return ►vith the individual's l
spouse_)(Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted]See reverse for details. TOTAL S
UWe certify under penalty of penury that the above and foregoing information is true i6,7and correct.
,i Sign f . •.•.,.-•n Date (month, day, year)
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ess of Ap• cant (n r ands eel city, ate, and ZIP code)
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Signature of Authorized Representative ' 0 Date (month. day, year)
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Address of Authorized Representative (number and street, city, sit rid ZIP ••
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Signature unty Auditor _ O `'rrtilliA Date (morifti y )
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DISTRIBUTION: Original - County Auditor; File-Stamped Copy - Taxpayer ,,