HomeMy WebLinkAboutAge_Hartley (5) ,''` '4, APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
`� PROPERTY TAX BENEFITS . V
State Form 43rt38 (R19/ 7-25) `J n ( C 1 n (\ ac) CQ
ice• 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 fled 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 bled 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 qualifications
Type of Benefit Requested (Please check all that apply) f
®Over 65 Credit El Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer) Telephone Number Email Address
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Is Applicant the Sole Lela'or Equitable Owner? If too, What is Applicant's Exact Share of Interest' If Owned with Joint Teiu.nnt ur Tenant in Common. Indicate with Whom
'Yes El No _
tf Name on Record is DifTerent than Applicant. Indicate Below Do NI Joint Tenants or Tenants in C Reside on the Property'?
Yes El No
Name of Contract Seer Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One(I)Year before Clairreng
Yes ❑No
Address of Contract Seiler (number and street, city, state, and ZIP code) Is the Property in Question
Real Property 0 Mobile Home (lC 6 1 1 -7)
Taxing Distract Key Number i Legal Description Record Number Page Number
� \CX: \C y \ L. - 1st-C7- 1C - - c (J r s-) `-i - C ,
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 indrviduars homestead property in the immediately 0 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? Er Yes ❑ No
Applicant's Date of Birth (month, day. year) If Fled by a Surviving, Unmarried Spouse.What Was the Spouse's Age at the Time of Death'?
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Source of Income Amount of Income
Adjusted Gross Income (AGI)of applicant, applicant aid spouse.or applicant '
and joint tenants or tenants in common, as applicable(For Over 65 Credit, AGI
may not exceed (1)$60,000 for indrvduals who filed a single return, (2) $70,000 for (-' ,) s / /1 (mdrvrduals who fled a joint return, or (3) S70,000 fix individuals and ar others that �! j (c'
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share owners*as pint tenants or tenants in common For the Over 65 Como(
Breaker Crew,AG!may not exceed (1) $60,000 for individuals who fled a single _..9S r '- r L
return, or(2)$70,000 for individuals who filed a pint return with the i viduat's U _ - - -
spouse)[Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adiusted J See reverse for details. TOTAL S -- - -:-
INVe certify under penalty of perjury that the above and foregoing information is true and correct
Signature of Applicant // Date (month, day, year)
. )�-Li/' `77- X - 4 G.
Address of Applicant(number and street, dty, stale, and'ZIP code) CV
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Signature of Authorized Representative I Date (month, day, year) 5
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Address of Authorized Representative (number and street, city, state, and ZIP code) LI.) CO
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Signature of County Auditor Date (month, day, year) U
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DISTRIBUTION: Original - County Auditor, File Stamped Copy - Taxpayer
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