HomeMy WebLinkAboutAge_MastersAPPLICATION FOR SENIOR CITIZEN
PROPERTY TAX BENEFITS COUNTY TOWNSHIP YEAR
State Form 43708 (1120 / 5-26)
Prescribed by the Department of Local Government Finance
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.
T of Benefit Requested (Please the all that apply)
14LOver 65 Credit
Name of Applicant 4A (owne or contract buyer) Telephone Number
c 6ra C� `1'1- 69 t3
I pplicant Sala L I or Equitable Owne If No, What is Applicanrs Exact Share or Interest?
'I - I -
If Name on Record is Different than Appli6nt, ndicate Below
Name of Contract Seller
Address of Contract Seller (number and street, city, state, and ZIP code)
' '"'],Uq`��;^ ey Number /Legal Description � pe
pg g
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?
VOver 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?
❑ Yes ❑ No
Has Applicant Owned or Bought the Property Under Recorded Contract
for at Least One (1) Year before Claiming Credit?
❑ Yes ❑ Ne
Is the Property in Question:
❑ Real Pro rt• ❑ Mobile Home (IC 6-1.
Record Number Page Number
U Yes LJ No
❑ Yes ❑ 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 =C01 Applicant's Date of Birth (month, day, year) If Flied by a Surviving, Unmarried Spouse, What Was the Spouse's Age at the Time of Death?
^ag--.� y OP-M M „ _ J n
:?
Adjusted Gross Income (AGQ of applicant, applicant and Source of Income
and joint tenants or tenants In common, as applicable ' or applicant
may not exceed.* (1) $6Q000 forindlvlduals who fled a single (2) $765 ��00 for
Individuals who hied a Joint return, or (3) $70, 000 forindividuals and all others that
share ownership asNnt tenants or tenants in common. For Me Over 65 LaWt
Breaker Credit AGI may not exceed.• (9) $60,000 forindNlduals who filed a single
relum; or (2) $70, 000 for lndh4duals who rifled a joint return with the indWduars V
spouse.) [Beginning with Pay 27, income amounts for the Circuft a►eaker Credit are
annually adjusted] See mvww fordehdl&
I/We certify under penalty of perjury that the above and foregoing information Is true and correct
ii re of Applicant
Date (month, day, year)
A rn
►ddress of lo-2
Appli nt (mum nil street, city, state, and ZIP code)
V11V
utho d Representative
10 ) _ ,,e _ �l . _ �. Date (month, , ye
IT Autfionzed Representative (number and street, city, state, and ZIP code)
oh,b 0
of County Auditor to
1 A n ► rlt- e^, Date (month.
DISTRIBUTION: Original — County Auditor; File -Stamped Copy — Taxpayer
Amount of Income
$ /Y335,o0
'3 0 89D aD
TOTAL 1$