HomeMy WebLinkAboutAge_VaughtTut APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
4 State Form 43708 (R2015-26)
k'eiB � P 'b d b th D artment of Local Government Finance
COUNTY
TOWNSHIP
YEAR
resc, e y e ep
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 calen pre� in
IF
which the property taxes are first due and payable.
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See reverse side for additional instructions and qualifications.
Type of Benefit Requested (Please check ll that apply) 12 6: . 40)
nxrPr RR (.mrlit F2 Over 65 Circuit maker Credit
e of Applicant (owner or ntract buyer)
71
Telephone Number
Email Address
Gi6sO/v Co Q
Is Applicant theSole Legal or Equitable Owner?
If No, What is Applicant's Exact Share or Interest?
If Owned with Joint Tenant or Tenant in Com 4to OR with Whom
Z Yes ElNo
If Name on Record is Different than Applicant, Indicate Below
Do All Joint Tenants or Tenants in Common Reside on the Property?
LvYYes ❑ No
Name of Contract Seller
Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before Claiming Credit?
1' Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code)
Is the Property in Question:
^
G"Real Property ❑ Mobile Home (IC 6-1.1-7)
Taxing District
Key Number / Legal Description
Record Number
Page Number
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
in immediately
❑
❑ No
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead property the
Yes
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?
❑ Yes
❑ No
Applicant's Dateof, iirthh (mo h, day, year)
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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
may not exceed: (1) $60,000 for individuals who filed a single return; (2) $70, 000 for
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$
individuals who filed a joint retum; or (3) $70,000 for individuals and all others that
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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
$70,000 forindividuals filed return with the individuals
retum; or (2) who a joint
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.
Signaajre of Applicant Date (month, day, yea )
.Address of pplicant (numb e nd streWcity, st
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and Z/P.co e)
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Signature of Authorized Representative
Date (month, day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code)
Sig to e of Co my Auditor I Date (month day,�ar)1� �Al ab lozvab
DISTRIBUTION: Original — County Auditor; File -Stamped Copy — Taxpayer