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APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS COUNTY TOWNSHIP YEAR
J State Form 43708 (R19 / 7-25)
`'-•"- Prescribed by the Department of Local Government Finance
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)
ver 65 Credit
Name of Applicant (owner or contract buyer) Telephone Number
kicA
Is Applicant the Sold Legal or Equitable Owner? If No. What is Applicant's Exact Share or Interest?
tx-J Yes U No
If Name on Record is Different than Applicant, Indicate Below
Name of Contract Seller
Address of Contract Seller (number and street, city, state, and ZIP code)
fiver 65 Circuit Breaker Credit
Email Address
If Owned with Joint Tenant or Tenant in Common, Indicate With Whom
Do All Joint Tenants or Tenants in Common Reside on the Property?
❑ Yes No
Has APPlicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before CL-timing CTW
Yes ❑ No
Is the Property in Question:
t� meal vroperty U Mobile Home (IC 6-1.1-7)
Ts District 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
a deceased 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 yeah
Is the Applicant 65 Years of Age or More on December 31 of the Year Prior to the Year Taxes are First Due & Payable? No
Yes
Applicant's Date of Birth ,
n (month, dayar)If Filed by a Surviving, Unmarried Spouse, What Was the Spouse's Age at the Time of Death?
CCrG�iix, 6 !o aZ3 49S.Z (�an)ee_ �'B-/9SS
Adjusted Gross Income AGI of Source of Income Amount of Income
j 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 tried a single return, (2) $70,000 for 7 OZL� $
Individuals who filed a joint return, or (3) $70,000 for individuals and aB others that N v l
share ownership as jmt tenants or tenants in comrrnon. For the Over 65 Circuit
Breaker Credit, AGI may not exceed (1) $60, 000 for individuals who filed a single � /n �r C ( Lf $ '
return, or (2) $70, 000 for individuals who filed a joint return with the Indkddual''s
WAxis-) Pegrrrrrng wlih Pay 27, income arnounis for Me Circuit Breaker Credn are
annually adjusted j 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 l'y)) Date (month, day, year) 0
Address of Applicant (number and str t ,state, and Z )
eo C
o a
s Ue-11 u452
Signature of Authorized Representative Date (month, day, year) r—
C
Address of Authorized Representative (number and street, city, state, and ZIP code) Z
C
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Signature of County Auditor m
Date (month, day,year) C7
DISTRIBUTION: Original — County Auditor, File -Stamped Copy — Taxpayer