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-"� APPLICATION FOR SENIOR CITIZEN
` PROPERTY TAX BENEFITS
State Form 43708 (R20I 5-26)
Prescribed by the Department of Local Government 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 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 Over 65 Circuit Breaker Credit
N i6e of Applicant (owner or contract buyer)
a, elb�,-
Telephone Number
(M )
Email Address
Is A cant the Sole L gal 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?
❑ Yes ❑ No
Name of Contract Seller
Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before Claiming Creaa
Yes ❑ No
Address of Contract Seller (number and street, city, state, and ZIP code)
in
Pro in Question:
I;Real
❑ Mobile Home (IC 6 1,1-7)
xin PDistr,ict r Key Number I Legal Description
2 —60
Record Number
Page Number
f' el2jV� inns - - — ,
Yes
❑ No
Does Applicant reside on the real prope y, mobile home, or manufactured home?
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 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 Date of Birth (month, day, year)
If Filed by a Surviving, Unmarred Spouse, What Was the Spouse's Age at the Time of Death?
9—V -/ Sd
9
Source of Income Amount of Income
Adjusted Gross Income (AGI) of applicant, applicant and spouse, or applicant
Over 65 Credit, AGI
/ (
and joint tenants or tenants in common, as applicable (For
$60,000 for individuals who filed a single retum; (2) $70,000 for
/ f) ®
$
c` L� O / 14,
may not exceed: (1)
tV
individuals who filed a joint retum; or (3) $70,000 for individuals and all others that
For the Over 65 Circuit
(C�
share ownership as joint tenants or tenants 0, common.
Breaker Credit, AGI may not exceed: (1) $60000 for individuals who filed a single
L.IL ((��
2oa O
$ + /—
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return; or (2) $70, 000 for individuals who filed a joint retum with the individual's
spouse.) [Beginning with Pay 27, income amounts for the Circuit Breaker Credit an
TOTAL
$
annually adjusted.] See reverse for details.
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
ignature of Applicant Date (month, day, year)
All
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Address of plicant (number and street, city, state, I1code) cv
o
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Signature of Authorized Representative Date (month, day, year) N
Address of Authorized Representative (number and street, city, state, and ZIP code)
Si Auditor
Date (month, day, year)
7ufCunty
D
DISTRIBUTION: Original — County Auditor; File-StanC�Ccpy — Taxpayer