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APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
State Form 43708
(R1819-24)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
ISOUNTY
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 the county auditor or postmarked by January 15 of the ca, endar 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 Deduction from Assessed Valuation EP3 Over 65 Circuit Breaker Credit
N me 1 Ap lirant( w r or contract buyer) Telephone Number Email Address
Is Applicant the Sole Legal or Equitable Owner? If�1G@�Vf Vtt is F � I act S b a r } e�yr-
If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
Er -yes ❑ No (( OOII c
If Name on Record is Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
Name of Contract Seller �<Yes ❑ No
Has Applicant Owned or Bought the Property Under Recorded Contract for at Least
One (1) Year before Claiming Deduction? Yes ❑ NO
Address of Contract Seller (number and street, city, state, and ZIP code) Is the Property in Question:
❑ Taxing Distric Key Number /Legal Description Real Property Mobile Home (1C 6-1.1-7)
Y / ! Record Number Page Number
(� �i ooa . Vqq -oa
Does Applicant Reside on Property? Assessed value of the property as of current year assessment date (May not exceed $240,000 for Over 65 Deduction or
$199,999 [counting just the homestead site] for the Over 65 Circuit Breaker Credit received before January 1, 2020, $199,999 tall
;14Indiana real property] for the Over 65 Circuit Breaker Credit initially applied for after December 31, 2019 and before January 1, 2023,
es ❑ No and $239,999 fall Indiana real property] for the Over 65 Circuit Breaker Credit initially applied for after December 31, 2022.) See
reverse for details.
Is the Applicant 65 Years of Age or More on December 31 of the Year Prior Applicant' Date of firth month, d year) If Fled by a Surviving, Unmarried Spouse, What Was the
to the Year Taxes are First Due &Payable? Yes ❑ No�� Spouse's Age at the Time of Death?
Adjusted Gross Income (AGI) of applicant, applicant and spouse, or applicant
and joint tenants or tenants in common, as applicable (For Over 65 Deduction, AGI may Source of Income Amount of Income
not exceed: (1) $30,000 (orindividuais who filed a single return; (2) $40,000 forinJi iduals
who filed a joint retum; or (3) $40, 000 forindividuals and all others that share ownership as OL $
joint tenants or tenants in common. For the Over 65 Circuit Breaker Credit, AGI may not D $
ome amounts ar
exceed: (1) $30,000 for individuals who filed a single return, or (2) $40,000 for individuals who
filed a joint return with the indiviindividualsspouse.) [Beginning with Pay 24, inc e a
annually adjusted.] See reverse for details. a 0 C �� TOTAL $ � Have You Filed for Any Other Deductions? IF Yes, 4tDtions?
XYes ❑ Novl����
Have You Filed for Deduction in Any Other County? If Yes, What County?
❑ Yes No '
Me certify under penalty of perjury that the above and foregoing information is true and correct.
Signature ofApplic t Date (month, da ,year)
Address of Applicant (number and street, city, state, and ZIP code)
30
Signature of Authorized Representative
ate (month, day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code) Ar
Signature of County Auditor 102s
- Date (mon
0. O
DISTRIBUTION: Original — County Auditor; File -Stamped Copy —Taxpayer
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