HomeMy WebLinkAboutAge_Lavanwayy APPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS COUNTY TOWNSHIP YEAR
State Form 43708 (R20 / 5-26) !L \ _
Prescribed by the Department of Local Government Finance � G� 1 c x \
76
Information contained in this document is CONFIDENTIAL pursuant to 1C 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)
fN Over 65 Credit
Name of Applicant (owner or contract buyer) Telephone Number
icatnc> �C` (AL-Gvc��c, �� 1,9, ) C.QU -I -19oZ
Is Applicant the Sole Legal or Equitable Owner? If No, What is Applicant's Exact Share or Interest?
L"Yes ❑ No
If Name on Record is Different than Applicant, Indicate Below
Name of Contract Seller
Address of Contract Seller (number and street, city, state, and ZIP code)
Taxing District Key Number / Legal Description
671,0ver 65 Circuit Breaker Credit
Email Address
If Owned with Joint Tenant or Tenant in Common, Indicate with Whom
Do All Joint Tenants or Tenants in Common Reside on the Property?
RrYes ❑ No
Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before Claiming Credit?
h' Yes ❑ No
Is the Property in Question:
Eg'-Real
-Ili avo-oz)4-1,
Does Applicant reside on the real property, 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
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 n u D.,...,
Applicant's Date of Birth (month, day, year)
} cl� CQ 1 G H 7
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
individuals who filed a joint retum; 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, AGI may not exceed., (1) $60, 000 for individuals who filed a single
return; or (2) $70, 000 for individuals who filed a joint return with the individual's
spouse.) [Beginning with Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted.] See reverse for details.
❑ Mobile Home (IC 6-1.
Record Number IPage Number
L�Yes
2"Yes
C�1 Yes
LJ No
❑ No
❑ No
If Fled by a Surviving, Unmarried Spouse, What Was the Spouse's Age at the Time of Death?
Source of Income
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
iianature of e�..r..<,...
1,
Address of Applicant (num era d street, city,
.._.. �, . • --au representative
drld IIt' Corre)
-• -- iui 4uu representative (number and street, city, state, and ZIP code)
signature of County Auditor
ISTRIBUTION: Original — County Auditor; File -Stamped Copy — Taxpayer
X
TOTAL I$
U
"nth, day, year)-a,3-a�),
Date (month, day, year)
Date (month, day, year)
Amount of Income
0