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APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS
State Form43708 (R20 /5-26)
ie Prescribed by the Department of Local Government Finance
COUNTY
TOWNSHIP
YEAR
n
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 riled 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 checkallthat apply)
D10ver 65 Credit L411ver 65 Circuit Breaker Credit
Name of Applicant (owner or contract buyer)
Telephone Numbbe�rq
Email Address
Is Applicant tbgptole Legal 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
Vies ❑ No
If Name on Record is Different than Applicant, Indicate Below Do All Joint Tenants or Tenants in Common Reside on the Property?
t2 es El 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 m Question:
=ealoperty ❑ Mobile Home (IC 6-1.1-7)
Taxing District Key Number / Legal Description Record Number Page Number
IC16--Mq P
Does Applicant reside on the r roe
PP property. rty. 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 to
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead property in the immediately
14es
❑ 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)
_q_
If Fled 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
j � ) PP k PP P PP
Source of Income
Amount of Income
$
LA
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 return; or (3) $70, 000 for individuals
and all others that
share ownership as joint tenants or tenants in common. For the Over 65 Circuit
Breaker Credit, AGJ may not exceed: (1) $60, 000 for individuals who riled a single
.
$
return; or (2) $70, 000 for individuals who filed a joint return with the individual'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 plicant
` Date (month, day, year)
Address of A licant (num er and street, ffity, state, and ZIP code)
jm-�,
Signature of Authorized Representative Date (mont da ar
Address of Authorized Representative (numberand street, city, state, and ZIP code)
ILED
Signature of County Auditor
Date (month, day, year)
DISTRIBUTION: Original — County Auditor; File -Stamped Copy — Tax yer
/ h"rh� a.
GIBSON COUNTY AUDITOR