HomeMy WebLinkAboutAge_Thompson (2)APPLICATION FOR SENIOR CITIZEN
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PROPERTY TAX BENEFITS
State Farm 43708 (RI 917-25)
Prescribed by the Department of Local Govemment 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 properly 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
Na/me of Applicant (own prcontract b er)
Telephone Number
Email Address
Is Applicant the Sole Legal or EqL11table 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
IP 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 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 [:1 Mobile Home (1C 6-1.1-7)
Taxin -0istrict Key Number /Legal Description Record Number Page Number
Did Applicant qualify for the homestead standard deduction in the preceding year (or was applicant married at the time of death to
deceased
a spouse who qualified for a homestead standard deduction for the Individual's homestead property in the immediately
Yes
No
preceding calendar year) and does Applicant qualify for the homestead standard deduction in the current year?
i
the Applicant 65 Years of Age or More on December 31 of the Year Prior to the Year Taxes are First Due & Payable?
hIs
Yes
i
❑ No
Applicant's Date of Birth (month, day, year) ,
c CU . 1
If Filed by a Surviving, Unmarried Spouse, t Was the Spouse's Age at the Time of Death?
Adjusted Gross Income (AGI) of applicant, applicant and spouse, or applicant
Source of Income
Amount of Income�
and joint tenants or tenants in common, as applicable (ForOver65 Credit, AGI
may not exceed: (1) $60, 000 for individuals who fifed a single return, (2) $70,000 for
individuals who filed a joint return, or (3) $70,000 for individuals and all others that
-
$
sham ownership as joint tenants or tenants in common. Forthe Over 65 Circuit
Breaker Credit, AGI may not exceed: (1) $60,000 for individuals who filed a single
$
return, or (2) $70,000 for individuals who filed a joint return with the individuaI'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 (number and street city, st ZIP code)
Signature of Authorized Re resentative Date (mont y, a
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Address of Authorized Representative (number and street, city, state, and ZIP code) f a.
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Signature of County Auditor 6
Date (month, day, year) ll
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DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer
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