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�.` `T'44 APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
Ill.:, PROPERTY TAX BENEFITS
•
. ,. State Form 43708 (R19 1 1 25) �t--) f�
�• Prescribed b the Department of Local Government Finance V -
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._y ) yl),) sq.__ -2 Tho ,.....20 1 E
Type of Benefit Requested (Please c c all that apply)
Over 65 Credit Over 65 Circuit Breaker Credit
C
of Applicant (owner or coneb r) Telephone Number Address
y
Is Applicant • • Legal Equitable Owner? If No. What is Applicant s Exact Share or Interest? If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
IR Yes ❑ No -
If Name on • • d is Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
I,d Yes El No
Name of Contract Seller Has Applicant Owned or Bought the •It: Under Recorded Contract
for at Least One(1)Year before •• • edit?
ri Yes D No
Address of Contract Seller (number and street, city, state, and ZIP code) Is the Property in Question
cl Real Property ❑Mobile Home (IC 6 1 1 /)
(axing Distnct Key Number/Legal Descnpt on Record Number Page Number
07J
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 Prix to the Year Taxes are First Due& Payable? Yes ❑ No
Appicant's D to o Birth (month, day, year) if Filed try a Surviving. Unmarried Spouse.What as the Spouse's Age at the Time of()eath7
— S
S 5T` (5- — 1 \16 SaD _
Source of Income Amount of Income
Adjusted Gross Income (AG1)of applicant, applicant and spouse, or applicant •
and joint tenants or tenants in common, as applicable (!-car Over 65 Credit, AG! �� '
.1 \ C L\c.
may not exceed (1) $60,000 for ind vdulls who feed a single return, (2)$70,000 for2 $
nckvrduals who filed a pant return, or (3) $70.000 for individuals and a/others that ) -
3re ownership as part tenants or tenants an common For the Over 65 Crcut Z \ 1 ‘g 2_____
Breaker Credit, AGI may not exceed (1) 560,000 for individuals who flied a srrgfe --)4° ) 6
return, or(2) $70,000 for rrxiwaldrrats who Ned a joint return with the rrdnnduat s _)
spouse.)[Begrrrwg with Pay 27, ',come arrv-xis for the Circuit Breaker Credit are
annually adjusted.]See reverse for details, TOTAL $
I/We &ertify under penalty of perjury that the above and foregoing information is true and correct.
�� � of Ap nt � --�j /;
Date (moot day, Tr t I CGS -- U ,/ ,
7 A.• of Applicant umber and street, city, , and ZIP code)
1 S-1D19— U-k1\ boo k -r , ?)• nv•N - -DI1- '1-)
Signature of Authorized Representative Date (month. day, year)
Address of Authorized Representative (number and street, city, state; and ZIP code)
Signature of County Audit() Date (month, day year)
l�,_� -� ) 2 .12.--.(D-
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DISTRIBUTION: Original County Auditor, F le-Stamped opy axpay ..,„