HomeMy WebLinkAboutAge_VitonAPPLICATION FOR SENIOR CITIZEN
x PROPERTY TAX BENEFITS
State Form 43708 (R2015-26)
Prescribed by the Department of Local Government Finance
COUNTY
TOWNSHIP
YEAR
�0
A �
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
Name of Applicant (owner or contract buyer)) Telephone Number
Email Address
Ph
Is App icant the Sole 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
es ❑ 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
�eS ❑ No
Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before Claiming
Address of Contract Seller (number and street, city, state, and ZIP code
�Credit?
' �S ❑ No
Is ;;Realro erty in Question;
District Key Number I Legal Description
Property Mobile Home (1C 6 1.1-7J
Pg
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
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead property in the immediately ❑
Yes
preceding calendar year) and does Applicant qualify for the homestead standard deduction in the current year? ❑ 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? ❑ Yes ❑ No
Applicant's Date of Birth (month, day, year) (�
Vim-
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 retum; (2) $70, 000 for
individuals who filed a joint return; or (3) $70, 000 for individuals and all others that
$ q
t-�
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
retum; 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 $ —
Me certify under penalty of perjury that the above and foregoing information is true and correct.
Signat of Appli�
17
Date (month, day, year)
re of Applicant (number and street, city, state, and ZIP code)
Signature of Authorized Representative
Date-(rylonth, day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code)
G
/eS
Signature of County Auditor
C Q u -�
Date (month, day, year) Jy
DISTRIBUTION: Original - County Auditor; File -Stamped Copy - TaxpayJ