HomeMy WebLinkAboutDisabilty_Mason 01,1 .„ APPLICATION FOR BLIND OR DISABLED PERSON'S
.V-' 0 DEDUCTION FROM ASSESSED VALUATION couNTY TOWNSHIP YEAR
0 f' State Form 43710(R12/10-16)
•• Prescribed by the Department of Local Government Finance Gibson 2019
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
INSTRUCTIONS:
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:Form must be completed and signed by December 31 and filed or postmarked by the following January 5.
2) Mobile Homes assessed under lC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
Polly S. Mason
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? --. ' own with someone other than spouse,
i .icat;with whom:
❑■ Yes El No tfi
If name on record is different than that of applicant,indicate below:
Name of contract seller 0
N/A •• 'P;,o��°R
Address of contract seller(number and street,city,state,and ZIP code) 1' Ci I vN�
G\�s°'t`1 Is the property in question:
0 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)?
O Yes ❑■ No O 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?
OYes El No El Yes 0No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
Princeton 26-12-07-303-003.415-028
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
;jteVyy1G11) 327 W. Pinkney St., Princeton, IN
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
0
You are entitled to hospital insurance under Medicare beginning October 2003.
You are entitled to medical insurance under Medicare beginning
December 2011.
Your Medicare number is 4R34-UHO-VJ89. You may use this number to get
medical services while waiting for your Medicare card.
If you have any questions, please log into Medicare.gov, or call
1-800-MEDICARE (1-800-633-4227).
Type of Social Security Benefit Information
You are entitled to monthly retirement benefits.
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