HomeMy WebLinkAboutAge_CampbellAPPLICATION FOR SENIOR CITIZEN
PROPERTYTAX BENEFITS
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State Form 43708 (R1917-25)
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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
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 thecounty 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 at/ that apply)
❑Over 65 Credit
® Over 65 Circuit Breaker Credit
Name of Applicant (owneror contract buyer)
Telephone Number
( Z ) CQ 3� - ZCD55
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?
® Yes
❑ No
Name of Contract Seller
Has Applicant Owned or Boughtthe Property Under Recorded Contract
for at Least One (1) Year before Claiming Cradit?
❑ 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 / Legal Description
Record Number
Page Number
Did Applicant quality for the homestead standard deduction in the preceding year (or was applicant married at the time of death to
a deceased spouse who for a homestead standard deduction for the individuals homestead in the immediately
El�y`es
❑ No
qualified
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?
❑ Yes
❑ No
Applicant's Date of Birth (month, day, yeah
If Filed by a Surviving, Unmarried Spouse, What Was the Spouse's Age at the Time of Death?
A �C c < �-
Source of Income
Amount
of Income
Adjusted Gross Income (AGI) of applicant, applicant and spouse, or applicant
and joint tenants ortenants in common, as applicable (ForOver65 Credit, AGI
may Trot exceed: (1) $60,000 for individuals who filed a single return, (2) $70,000 for
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, AG/ may not exceed. (1) $60,000 for individuals who filed a single
retum,or (2) $70,000 for individuals who filed a joint return with the individual''s
�(
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 (nuthberand street city, state, and,?JP 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
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Date (month, day, year/)
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DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer