HomeMy WebLinkAboutAge_BramesAPPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
.+� State Form 43708 (R20 / 5-26)
'd1O Prescribed by the Department of Local Government Finance
ID'k
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)
( Over 65 Credit a —Over 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer) Telephone Number Email Address
(8I--) ) gqn -LiQI, i S
Is Applicant the Sole egal 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?
Name of Contract Seller
❑ Yes ❑ No
Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before Claiming CC e it?
Address of Contract Seller (number and street, city, state, and ZIP code
' es ❑ No
Is the Property in Question:
Taxing District Key Number / Legal Description
Ly" Real Property ❑ Mobile Home (IC 6-1.1-7)
Record Number
��
Page Number
LA.03�-
Does Applicant reside on the real property, mobile home, or manufactured home?
es ❑ No
Did Applicant qualify for the homestead standard deduction in the preceding year (or was applicant married at the time of death o
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead roe in the immediately
preceding calendar year) and does Applicant qualify for the homestead standard deduction in the current year? Ctl'"Yes ❑ No
Is the Applicant 65 Years of Age or More on December 31 of the Year Prior to the Year Taxes are First Due & Payable? [a -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?
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 (For Over 65 Credit, AGI
may not exceed: (1) $60, 000 for individuals who filed a single return; (2) $70, 000 for
individuals who filed a joint
$ l
retum; or (3) $70, 000 for individuals and all others that
j I
share ownership as joint tenants or tenants in common. For the 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 individual''
$
I 1
spouse.) (Beginning with Pay 27, income amounts for the Circuit Breaker Cred it 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.
Signatf Apt p
1Y�u1 V �
Date (month, day, year)
Ad
ress of Applicant (number and street, city, state, and ZIP code)
Signature of Authorized Representative
Date (month, day, year) o
L 1
zozs
Address of Authorized Representative (number and street, city, state, and ZIP code)
B_,�
Signature of County Auditor
1
( Jar
Date mont � �1 (1; 1 AUpITOR
DISTRIBUTION: Original — County Auditor; File -Stamped Copy — TaxpayerU