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APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
State Form 43708 (R19/7-25)
+• b th D rtm t f t ocal Government Finance
COUNTY
TOWNSHIP
YEAR
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C L
Prescribed y e epa en o
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.15
instructions: To be filed in person or by mail with the county auditor of the county where the p is located.
Filing Date. Form inust be completed, signed, and filed with the. county uydltbr 4r 6b ked by January 15 of the calendar year in
which the property taxes are first due and payable CUB
See reverse side for additional instructions and qualifications.
Type of Benefit Requested (Please check all that apply) UIUj-t, 4f
A(/plr0p
❑aver 65 Credit J Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer)
Telephone Number �j -7
Email Address
Is Applicant the Sole Legal 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 Bought Me Property Under Recorded Contract
for at Least One (1) Year before Claiming Credit?-
❑ ❑
Yes No
Address of Contract Seller (number and street, city, state, and ZiP code)
Is the Property in Question:
R I Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District
Key Number / Legal Description �1
— U`` -- ---C I ^ �Q 1
- �
Record Number
Page Number
'
�.Q — 1
Goa
Did Applicant qualify for the homestead standard deduction In the preceding year (or was applicant married at the time of death to
homestead in the Immediately
❑ Yes
❑ No
a deceased spouse who qualified for a homestead standard deduction for the individual's property
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, yeah
if Filed by a Surviving, Unmarried Spouse, What Was the Spouse's Age atthe Time of Death?
qr
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 filed a single return, (2) $70,000 for
O
$
individuals who filed a joint return; or (3) $70,000 for individuals and ail others that
— V
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 fled a single
$
return, or (2) $70,000 for individuals who filed a join treturn with the individual's
TOTAL
$
spouse.) [Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annualtyadjusted] See reverse fordetails.
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I/We certify under penalty of perjury that the above and foregoing information is true and correct
Signature of Applicant- (
Date (month, day, year)
47-
Address of Applicant (number and street city, stale, and-ZiWcode)
Signature of Authorized Representative
Date (monfh, day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code)
Signature of County Auditor ^ � Date (month, day, year)
all
DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer