HomeMy WebLinkAboutAge_BlackburnAPPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
State Form 43706 (R1917-25)
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Proscribed 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
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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 tho 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)
Over 65 Credit ❑/Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer)
Telephone Number
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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?
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❑ 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 (iC 6-1.1-7)
Taxing District
Key Number i 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
homestead deduction for the Individual's homestead in the immediately
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❑ Yes
❑ No
a deceased spouse who qualified for a standard 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?
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❑ Yes
❑ No
Applicant's Date of Bir�rtth (month, day, year) 7 (�
tr Fled by a Surviving, Unmarred Spouse, What Was the Spouse's Age at the Time 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 common, as applicable (For Over 65 Credit, AGI
may not exceed: (1) $60,000 far individuats who filed a single return; (2) $70,000 for
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individuals who filed a joint return, or (3) $70,000 for individuals and all 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 forindividuals who Recta single
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return; or (2) $70, 000 for individuals who filed a joint return with the individual's
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spouse_) [Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted] See reverse for details.
TOTAL
I/We certify under penalty of perjury that the above and foregoing information is true and correct -
Signature of Applicant
Date (month, day, year)
Address of Applicant (number and street, city, state, and ZIP code)
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Signature of Authorized Representative I
Date (month, day, year) g"
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Address of Authorized Representative (number and street city, state, and ZIP code) Sri
Signature of County Auditor
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Date (month, day, year)
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DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer