HomeMy WebLinkAboutAge_ChavisAPPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
a' State Form 43708 (R20 15-26)
i
Prescribed by the Department of Local Government Finance
COUNTY
TOWNSHIP
YEAR
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.
Type of Benefit Requested (Please check all that apply) �%
Credit
C'2Over 65 Credit Lis Over 65 Circuit Breaker
Name of Applicant (owner or contract buyer) Telephone Number
Email Address
(b)� ) ��7^ 'Ly U,-� /
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Is Applicant theSole Legal or E uitable Owner? If No, What is Applicant's Exact Share or Interest? If
Owned with Joint Tenant or Tenant in Common, Indicate with Whom
Ltd Yes ❑ No
If Name on Record is Different than Applicant, Indicate Below
Do All Joint Tenants or Tenants in Comm/Ion Reside on the Property?
❑
Rr Yes No
Name of Contract Seller
Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before Claiming Cr it?
Yes ❑ No
Address of Contract Seller (number and street, city, Nate, and ZIP code) Is Pro erty in Question:
� Property ❑ Mobile Home (IC 6-1.1-7)
;Real
Taxing District er /LegalDescriptionRecord Number Page Number
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_� -LICE '-�. U—�
Does Applicant reside on the real property, mobile home, or manufactured home? Yes ❑ No
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 property in the immediately
52rYes
❑ No
a deceased spouse who qualified for a standard
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?
LJ Yes
❑ No
Applicant's Date of Birth (month, day, year)
If Filed 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
for
`
$
may not exceed: (1) $60,000 for individuals who filed a single return; (2) $70,000
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
$60,000 for individuals who filed a single
$
Breaker Credit; AGI may not exceed. (1)
`(
retum; or (2) $70,000 forindividuals who filed a joint return with the individual''s
spouse.) [Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
TOTAL
$ �—
annually adjusted.] See reverse for details.
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 d street, city, state, and ZIP code)
! n �0 O
Signature of Authorized Representative Date (month, day, year) LM F
v
N
Address of Authorized Representative (number and street, city, state, and ZIP code) �9 t
t
Signature of County Auditor
Date, day, year)
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col),k);), 12
DISTRIBUTION: Original — County Auditor; File -Stamped Copy — Taxpayer