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HomeMy WebLinkAboutAge_StrangAPPLICATION FOR SENIOR CITIZEN PROPERTY TAX BENEFITS State Form 4370E (R1917-25) Prescribed by the Department of Local Government Finance Information contained in this document is CONFIDENTIAL pursuant to IC 6-1A-35-9. COUNTY TOWNSHIP YEAR 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 postrnarked 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. Type of Benefit Requested (Please check all that apply) I Over 65 Credit LUllver 65 Circuit Breaker Credit Name of Applicant (owner orcontract buyer) �!rIC S4-1.0-n Telephone Number C '09_41-'AL 0/ � - F 5 / - %©a � Email Address Is Applicant the Sole Le 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 Yes ❑ No If Name on Record Is Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property? ❑ Yes ❑ No Name of Contract Seller Has Applicant Owned or Boughtthe Property Under Recorded Contract for at Least One (1) Year before Claiming Credit? ❑ Yes ❑ No Addrrejss of Contract Seller (number and street city, state, and ZIP code) %� t� % 3- � oa kl r f- ��(� Is the Pr erty in Question: ✓ / ,�r , C al,11_ oml, OLf Real Property ❑ Mobile Home (iC 6-1.1-7) Tax Dis`triict Key Number I Legal Descriptio Record Number Page Number M Did Applicant qualify for the ho stead 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 ❑ 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? Yes ❑ No Applicant's Date of Birth (month, day, year) if Filed by a Surviving, Unmarried Spouse, What Was the Spouse's Age at the Time of Death? Adjusted Gross Income (AGI) of applicant, applicant and spouse, or applicant Source of Income Amount of Income �— $ and joint tenants or tenants in common, as applicable (For Over 65 Credit, AGI may not exceed: (1) $60, 000 for individuals who fired a single return, (2) $70,000 for individuals who filed a joint return; or (3) $70,000 for individuals and a0 others that share ownership as joint 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 $ return,or (2) $70,000 for individuals who filed a joint return with the individuaI's c e spouse.) [Beginning with Pay 27, income amounts for the Circuit Breaker Credit are o annually adjusted.] See reverse for details. TOTAL $ cl_,� co Me certify under penalty of perjury that the above and foregoing information is true and correct. �-- Slonature of 7I Y_�t -.91 - Date (month, day, year) I 61_�_ Address of Appllcan uwjm r eet, &( state and P code) / [���/_ n �111 fV 2111 D, oylel �lV / l,/UO&o Signature of Authorized Representative Date (month, day, year) Address of Authorized Representative (number and street, city, state, and ZIP code) Signature of County Auditor a Date (month, day, year) 5- x eLz& DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer