HomeMy WebLinkAboutAge_Farris (2)APPLICATION FOR SENIOR CITIZEN
fyi1 PROPERTY TAX BENEFITS
State Form 43708 (R1917-25)
Prescribed by the Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
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 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 t apply)
Q Over 65 Credit 061r 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer)
Telephone Number
Email Address
u as oel 5
385--6 (D 9 5
Is Applicant the Sol egal or Equitable Owner?
If No, What is Applicants Exact Share or Interest?
If Owned with Joint Tenant or Tenant in Common, Indicate with Wham
LO�Yes ❑ No
If Name on Record is Different than Applicant, Indicate Below
Do All Joint Tenants or Tenants in Common Reside on the Property?
es ❑ 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 s% t, city, state, and ZIP coddee))/�
130,E �GID L9 - Pr(r)ce,464i7L, `�'" �V a70
Is the Property in Question:
eal Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District
Key Number / Legal Description
Record Number
Page Number
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Did Applicant qualify for the homestead standard deduction in the preceding year (or was applicant married at the time of death to
❑Yes
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead property in the immediately
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preceding calendar year) and does Applicant quality 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?
es
❑ No
Applicant's Date of Birth day, year)
s Age at the e of Death?
If Fled by a Surviving, Unmarried Spouse, What Was the SpouseTime
/(month,
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Source of Income
Amount of Income
Adjusted Gross Income (AGI) of applicant, applicant and spouse, or applicant
Over 65 Credit, AGI
and joint tenants or tenants in common, as applicable (Far
may not exceed: (1) $60,000 for individuals who Ned a sirve reMm, (2) $70,000 for
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individuals who filed a joint return, or (3) $70,000 for individuals and a9 others that
share ownership as joint tenants or tenants in comm. For the Over 65 Ciuxril
I / / / ! /
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$ /�
Breaker Credo AGI may not exceed: (1) $60,000 for individuals who Ned a single
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return, or (2) $70, 000 for individuals who riled a joint return with the irdivrdual's
spouse.) [Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted) See reverse for details.
TOTAL
$ D
I/We certify under penalty of perjury that the above and foregoing information is true and correct_
Signature of A plicant
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Date (month, day, year)
Address of Applicant (numberand street, city, state, a IP code) cv }
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Signature of Authorized Representative
Date (month, day, year) tY U
t1
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Address of Authorized Representative (number and street city, state, and ZIP code) ro
Signature of County Auditor
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Date (month, day, year)
4/15 aOaz
DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer