HomeMy WebLinkAboutAge_Dougan<H°"= APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
State Form 43708 (R20 / 5-26)
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Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
COUNTY
TOWNSHIP
YEAR
G`0D--sa rn
Instructions: To be tiled 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)
El -over 65 Credit
L-Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer)
Telephone Number
Email Address
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If No, What is Applicant's Exact Share or Interest?
If Owned with Joint Tenant or Tenant in Common,
Indicate with Whom
Is Applicant the Sole Legal or Elqditable Owner?
MYes ❑ No
If Name on Record is Different than Applicant, Indicate Below
Do All Joint Tenants or Tenants in Common Reside
on the Property?
Z"Yes
❑ No
Name of Contract Seller
Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before Claiming Crree it?
EI Yes
❑ No
Address of Contract Seller (number and street, city, state, and ZIP code)
Is the Property in Question:
I� Real Property ❑ Mobile
Home (IC 6-1.1-7)
Taxing District
Key Number / Legal Description
Record Number
Page Number
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Does Applicant reside on the real property, mobile home, or manufactured home?
Er Yes
❑ No
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
M" 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?
/
I l Yes
❑ No
Applicant's Date of Birth (month, day, year)
If Fled by a Surviving, Unmarried 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 for individuals who filed a single return; (2) $70, 000 for
L
$ 1
individuals who filed a joint return; or (3) $70,000 forindividuals and all others that
$ 1
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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 filed a single
return; or (2) $70,000 forindividuals who filed a joint return with the individual''s
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1
spouse.) [Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted.] See reverse for details.
TOTAL
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I/We certify under penalty of perjury that the above and foregoing information is true and correct.
S*natur plicant
Date (month, day, year)
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Address o Applicant (numb6fr and street, citystate, and ZIP code)
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Signature of Authorized Representative
Date (month, day, year)
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Address of Authorized Representative (number and street, city, state, and ZIP code)
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Signature of County Auditor
Date (month, day, year)
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DISTRIBUTION: Original - County Auditor; File -Stamped Copy - Taxpayer