HomeMy WebLinkAboutDisabilty_Harris (2) APPLICATION FOR BLIND OR DISABLED PERSON'S cou . �' TAI AR
r-- DEDUCTION FROM ASSESSED VALUATION '.
i' Slate Form 43710(R9/9-08)
\�•i• Prescribed by the Deparmtent of Local Government Finance I
10\1\
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). JA rl� aoll
INSTRUCTIONS: CI'l\aflr.-._.-.,
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought. GIBSON COUNTY AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve 1 )months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name oof applicant(owner or contract buyer)
Da( I en € fiQ1'i lJ
Is applicant the sde legal or equitable owner? if No,what is his/her exact share of interest? It owned with someone other than spouse,
��nr indicate with whom:
❑Yes ( No 50 DA,
If name on record is different than that of applicant,indicate below
//Doa(3 d-- Da A -r a 4a -fl s
Name of contract sefer
Address of contract seller(number and street,cay,state,and ZIP code) Is the property in question:
(4 Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7),
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
Dyes IZI No Vli Yes ❑No
Is the property used and occupied primarily for his/her residence? - Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000? 4�_ C ,� e Calxq_)5-I a,
^ q Yes ❑No a 1„-2.0 -15 _ RO y coo 0 7 a OD� ❑Yes T� ❑No
(`' Taxing district Ke • ••(Engel desai(fionr_ ir ; mrd.tmber� Page number
/ I _
I e certify and//penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and • ner of the aforementioned property on March 1, 20 .
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
/
� �.�.,_:� �1��, 196s 5. s r�Tt Rte, 57 yr���:k� i�� y7�s�
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
a nic,e emu arty ,urure-payments will go to the financial institution you
selected. Please let us know if you change your mailing address, so we
can send you letters directly.
• Later in this letter, we will show you how we figured these amounts.
The day we make payments on this record is based on your date of birth.
Information About Representative's Fees
We have approved the fee agreement between you and your representative.
Your past-due benefits are $18,648.00 for October 2009 through November 2010.
Under the fee agreement, the representative cannot charge you more than
$4,662.00 for his or her Work. The amount of the fee does not include any
out-of-pocket expenses (for example, costs to get copies of doctors' or
hospitals' reports). This is a matter between you and the representative.
Enclosure(s):
Pub 05-10153
p•1:, ris_i,n`15g