HomeMy WebLinkAboutAge_HulfachorAPPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS
• ,�i Slate Form 4370i3 (R19 / 7-25)
Prescribed by the Department of Local Government Finance
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.
apply)
Type of Benefit Requested (Please j;=,er65 Circuit Breaker Credit
Credit er
Name of Ap licant (owner or contract buyer)
Dcwi &I'Mrel yapo�ar
Telephone Number
(Piz ) 1 b4%5353
Email Address
Is Applidant 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
l.,fYes ❑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?
❑ Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code)
Is the Property in Question:
Real Property ❑Mobile Home (1C 6 1.1-7)
Taxing District
Key Number / Legal Description
4-D11-1j-
Record Number
Page Number
Did Applicant qualify for the homes! ad standard deduction in the preceding year (or was applicant married at the time of death to
Elyk-s—
❑ 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?
e5
❑ No
Applicant's Date of Birth (mo day, year)
1Jc-,v 9 22-197"B �cnarn� �f l9 �9
If Filed by a Surviving, Unmarried Space, What Was the Spouses Age at the Tone 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 corrxnon, as applicable (For Over 65 Credit AGI
may not exceed: (1) $60,000 forindividuafs who tied a single return; (2) $70,000 for
'T
b
individuals who liked a joint return, or (3) $70,000 for individuals and a9 others that
share ownership as j mt tenants or tenants in comm. For the Over 65 Circuit
A A
$
Breaker Credit, AGI may not exceed: (1) $60,000 for individuals who tia single
�ed C ! r
—
return, or (2) $70, 000 for individuals who fled a joint return with the irdmdual's
l
$
spouse.) /Beginning with Pay 27, income amounts for the Grcud Breaker Credit are
annualtyadjusted.]See reverse for details.
TOTAL
Me certify under penalty of perjury that the above and foregoing information is true and correct.
Signat Applicant
Date dray, year)
//(month,
Address of Applicant number and street state, and ZIP )
Signature of Authorized Representative
Date (month, day, year) iz
Cl-
Address of Authorized Representative (number and street, city, state, and ZIP code)
Signature of County Auditor%�
(_!l � I Y) 1V ��/5
Date (month, day, year)
1/ -1 5 -2,oZza
IN
DISTRIBUTION: Original — County Auditor; File -Stamped Copy — Taxpayer