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,�` ""' APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
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4. PROPERTY TAX BENEFITS
�� `, State Form 43708(R19 7-25) c_1 Son c\oA4 hp,{
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, . nm Prescribed by the Department of Local Goverent Finance `J - �v' 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.
Typeof Benefit Requested (Please check all that apply)
Over 65 Credit EiOver 65 Circuit Breaker Credit
Name of Applicant(owner or contract buyer) Telephone Number Email Address -
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pplicant the Sole a a or Equitable( ner? If No, What is Applicant's Exact Share or Irk? If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
'Yes ❑No
If Name on Record is Different than Applicant. Indicate Below Do All Joint Tenants cx tenant°: In Common Reside on the Property?
Yes ❑NO
Name of Contract Seller Has Applcant Owned or Bought the Property Under Recorded CorOract
for at Least One(1)Year before Ctarrwmg ❑NoYes
Li
Address of Contract Seiler (number and street. city, state, and ZIP code) Is the Property in Question
Real Property 0 Mote Home(IC 6-1.1-7)
Taxing District Key Number/Legal Description Record Number Page Number
( ' ( o A- i. C2(1)-)7- l`1 -13C0- ace\ . 6l 1_- \
Did Applicantjualify for the ho&estead 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 individual's homestead property in the immediatety 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 Pnor to the Year Taxes are First Due& Payable? (Yes 0 No
Applicant's Date of Birth (month, day, year) If Fled by a Surviving, Urmarned Spouse.What Was the Spouse's Age at the Time of Death?
Y -- : .2‘ (-0/aliclFc )i—c`-' -' ---/u)z.it J ,- 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 $
may not exceed (1)$60,000 for,nchoduals who filed a single velum,(2)S70,000 for I
ndvidc is who fried a pint return, or(3) $70,000 for ridiw that
duals and a/others at aC\R l �` �� ` L
share ownership as pint tenants or tenants in common For the Over 65 Circuf
Breaker Credit,AGI may not exceed' (1) S60,000 kx individuals who fried a single S `
return; or(2)$70,000 for ndrviduals who tied a pnt return with the ndrviidtkal's QCI) -- - - 1 LI ( -
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cice.)(Beginning with Pay 27, ricorrie amounts for the Circuit Breaker Creddt are
annually adjusted J See reverse for details. TOTAL $
UWe certify under penalty of per)ury that the above and foregoing information is true and correct.
Signature of Applicant Date (month, day, year)
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Address of n ber and street, city, stale, and IP ) ✓ -�
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Signature of Authorized Representative I Date (month, day, year) N O
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Address of Authorized Representative (number and street, (my, stale, and ZIP code) *Min) c a
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Signature of County Auditor Date (month, day, yew) n-
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DISTRIBUTION: Original - County Auditor, File-Stamped Copy - Taxpayer C7