Disabilty_Williamson • Reset Form
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` APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
IA '�1\ DEDUCTION FROM ASSESSED VALUATION
a. State Form 43710 (R14/9-24) P\--- 4
( 12a)n'' r cch_ o
'!�!~ 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 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.
Name of Applicant(owner or contract buyer)
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Is applicant the sole legal or equitable owner? If No, what is his/her exact share or interest? If owned with someone other than spouse, indicate with whom
0Xee ONo
If name on record is different than that of applicant, indicate below:
i
Name of Contract Seller
Address of Contract Seller (number and street, city, state, and ZIP code) Is the Property in Question:
eal Property O Annually Assessed
Motile 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)?
0 Yes t. e'r 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?
6irg: El No ❑ Yes U0145.
Taxing District Key Number/ Legal Description Record Number(contract) Page Number (contract)
F or` V ,c.o Z V1' `tQ - \ Dq - oct. O a 1.Q .
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)
4114.4., LA)412L.L."-.4.e•-• 53 IA . .
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Signature of Authorized Representative Address of Authorized Representative (number and treet, city, state, and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND I DISABLED PERSONS
Name of Applicant Date Filed (month, day, year)
Z‘k.. aarl rx- - I__>- •, LVia_nc..ki > FILED
Name of Contract Seller
Taxing District AU 2 9 2025
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Key Number/ Legal Description (AZ. a. iiirathi;nd)
` `A --. O �/ , n GIBBON COUNTY AUDITOR
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Signature of County Auditor Date Signed (month, day, year)
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SUSAN MARIE WILLIAMSON
804E VINE ST
PORT BRANCH IN 47648-1230
You are entitled to monthly disability benefits_
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