HomeMy WebLinkAboutAge_McClanahane. APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
�t
� f State Form 43708 (R19 / 7-25)
�y�r.%
, Prescribed DY the Department of Local Government Finance
COUNTY
TOWNSHIP
IYEAR
/
/
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.
Type of Benefit Requested (Please check all that apply)
Q Over 65 Credit
EfOver 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer)
Telephone Number
Email Address
L , ��' M-�
(3ic'�' ) `165 - '11-11
Is Applicant the ole 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
E(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
❑
Yes
No
Address of Contract Seller (number and street, city, state, and ZIP code)
Is the Property in Question:
EI(Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District
Key Number / 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
in the immediately
ffYes
❑ No
a deceased spouse who qualified for a homestead standard deduction for the individual's
homestead 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 December31 of the Year Prior to the Year Taxes are First Due & Payable?
E31/Yes
❑ NO
Applicant's Date of Birth (month, day, yeah
it Filed by a Surviving, Unmarred Spouse, What Was the Spouse's Age at the Time of Death?
4
7
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 fled a single return, (2) $70,000 for
L $
Li GI
individuals who filed a joint return, or (3) $70,000 for individuals and alf others that
share ownership asdoint tenants or tenants in common. For the Over 65 Claud
Breaker Credit AGI may not exceed: (1) $60,000 for individuals who fled a single
return, or (2) $70,WO for individuals who filed a pint return with the indVidual's
spouse.) (Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
TOTAL $
----�
annually adjusted-] See reverse for details.
I/We certify under penalty of perjury that the above and foregoi7 information is true and correct.
Signaturepf Applicant
Date (month, day, year)
Address of Applicant (number and street, city, state, and ZIP code)
rr
L t- . 1` C)
Signature of Authorized Representative
Date (month, day, year)
N
CI
o
N
Q
Address of Authorized Representative (number and street, city, state, and ZiP code)
M(V Z
Signature of County Auditor
Date (month, day, year)
iL
Z
' ACn
c-
1
Cn
m
NO
DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer