HomeMy WebLinkAboutAge_Ping (2)C61 APPLICATION FOR SENIOR CITIZEN
4' PROPERTY TAX BENEFITS
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\ State Form 43708 (R1917-25)
• �. Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
COUNTY
TOWNSHIP
I YEAR
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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 to
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)
Over 65 Credit [+Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer) Telephone Number Email Address
($lid ) Co'pa- 9�7s
2MC-u L. I t_
Is Applican the Sole Legal or Equitable OwTAO
If No, What is Applicants Exact Share or Interest?
If Owned with Joint Tenant or Tenant In Common, Indicate with Whom
IR(Yes ❑ No
It Name on Record is Different than Applicant, Indicate Below
Do All Joint Tenants or Tenants in Common Reside on the Property?
ErYes ❑ No
Name of Contract Seller
Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before Chang Credit?
Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code)
Is the Property in Question:
Q Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District
Key Number / Legal Description
Record Number
Page Number
01(9- - -oo\, OZ�Oq -0(91\
Did Applicant qualify for the h4nestead standard deduction in the preceding year (or was applicant married at the time of death to
[Yes
❑ No
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead property in the immediately
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?
ff 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?
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 individuals who fried a single return, (2) $70,000 for
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—J)�160
$ o •
individuals who filed a joint return, or (3) $70,000 for kidivioYrals and aff others that
share ownership as joint tenants or tenants in common. For the Over 65 Circuit
$
Breaker CrecK AGI may not exceed: (1) $60,000 forindmduals who tiled a sirgfe
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return, or (2) $70,000 for individuals who fled a joint return with the individuals!!
spouse_) (Beginrrng with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted_] See reverse for details.
TOTAL
$
IlWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant f}
Date (month, day, year)
Address of Applicant (number and street city, state, and ZIP )
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Signature of Authorized Representative
t.t—e(Month, day, year) H
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Address of Authorized Representative (number and street city, state, and ZIP code)
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Signature of County Auditor
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Date (month, day, year) O
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DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer