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APPLICATION FOR SENIOR CITIZ-r Lh
PROPERTY TAX BENEFITS
State Form 43708 (R19 / 7-25)
Prescribed by the Department of Local Government Finance
SAY 0. 2�p26..
Information contained in this document is CONFIDENTIAL pursuant to IC 6-i_1`35- .
COUNTY
TOWNSHIP
YEAR
Instructions: To be filed in person or by mail with the countypud itor of the county wl ere the property is located
Filing Date: Form must be completed, signed, and filed witI0im � by January 15 of the c
which the property taxes are first due and payable. DITOR �—
See reverse side for additional instructions and qualifications.
Type of Benefit Requested (Please check all that apply) ,,�
❑Over 65 Credit ❑.Over 65 Ckdi�BrwiAr2edit
f App it \'I (own, or contract buyer)
Tele hone Number
Email Address
Is Applicant the Sole Legal or Equitable Owner?
If No, What Is Applicant's Exact Share or interest?
U�,Indicate with Whom
If Owned ON
=M1
El 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 the Property Under Recorded Contract
for at Least One (1) Year before Claiming Credit?
0 ❑
Yes No
Address of Contract Seiler (number and street, city, state, and ZiP code)
Is the Property in Question:
Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District
C
Key Number I Legal Description
Record Number
Page Number
Did Applicant qualify for the homestead 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
.EI 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?
r
❑ Yes
❑ NO
Applicant's Date of Birth (month day, year) I
If Filed by a Surviving, Unmarried Spouse, What Was the Spouses Age at the Time of Death?
Adjusted Gross Income (AGI) . 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 retum; (2) $70,000 for
Source of Income
Amount of Income
%
$
individuals who filed a joint retum,or (3) $70,000 for individuals and aft 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 forindividuafs who filed a single
return, or (2) $70,000 for individuals who filed a joint return with the individual's
spouse.) [Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annualtyadjusted.]See reverse fordetails.
TOTAL
$
Me certify under penalty of perjury that the above and foregoing information is true and correct.
Sigma ure of Applicant
Dale (month, day, year)
Add' ss of Applicant (numberand.street city, te; and ZIP code)
ti
Signature of Authorized Representative
Date (month, day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code)
^
Sig ture of pounty Auditor
,.,�
Date (month, day year)-
41--d /0
U
DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer