Disabilty_Mason (2) APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
j -- :. DEDUCTION FROM ASSESSED VALUATION
1 '._ _ : State Form 43710(R12/10-16) \JV� 1 1�� `2.'Q 2 o
;+`; „?' Prescribed by the Department of Local Government Finance -
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. A
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:Fonn must be completed and signed by December 31 and
Name of applicant(owner or contract r ✓-
jell TN 1 3 1 Cit.51e)
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
)tes ❑No
If name on record is different than that f applicant,indicate b
T.,
ILED
Name of contract seller
JUL 9 2020
Address of contract seller(number and street;city,state,and ZIP cod s e property in question:
Real Property 0 Annually Assessed
GIBSON COUNTY AUDITOR 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)?
❑Yes ❑No kes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the pre ding calendar year
exceed$17,000?
1'Yes 0 No ►'d Yes ElNo
Taxing district Key number/Legal description Record number(.•n - ) Page number(contract)
V 'r\ , 2-6-11-01-Vil -001-2z)=oZp
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)
X0��;-,/i, -y,2 Q.6.0-.,,, �21 E s-�- _S� l- � — �1 —�9-6-
Sinet o uthorizeaGfe re -- .- Address of authorized representative number and street,city,state,and ZIP code)
P ( city
You can report changes in your work activity by phone, fax, mail, or in person. Call our toll-free
number 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday, or visit your local Social
Security office. You can find your local office by going to our website at www.socialsecurity.gov.
We will give you a receipt to verify your report. Keep this receipt with all of your other important
papers from Social Security.
Social Security Administration
Fonn SSA-L634(9-1986) EF(5-2000)