Disabilty_Hartley •
Mr, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
a.4-t_ _r o DEDUCTION FROM ASSESSED VALUATION
•-4.
' !:/ State Form 43710(R13/1-20)
Prescribed by the Department of Local Government Finance
File a
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. °C T 0.6 2020
Filing Date: Form must be completed and signed by December 31 and filed or postmarked by the following January pfthe calendar year in which the
property taxes are first due and payable.
See reverse side for additional instructions and qualifications. GIgSON ICI OUN7`)'AUDITOR
Name of applic t(owner or contract buyer)
W2I /1 L
Is ap c the sole legal or equitable owner? If No, at is her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑Yes %No
If name on record is differerit than that of applicant,indicate below:
..7()/C-eia,e„„,10i
Name of contract seller de)/60 4e41944( 22
eajd
Address of contract seller(number and street,city,state,and ZIP code) Is th roperty in question:
eal 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)?
❑ Yes No '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?
"'Yes ❑ No ❑Yeso
Taxin• . •trict Key number�/Legal description Record number(contract) Page number(contract)
/! ,. A'Q/T (JO-0QO•/.0-Oda.
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)
rA
x `3 9 • )� s- Iivu1
Signature of authorized repreentative Address of authorized representative (number and street,city,state,and ZIP code)
ims payment amount may change rruur 10011U1 w ruv,rui 11 un.vure vi itvulg aituauvii urauges.-
Supplemental Security Income Payments are paid the month they are due. (For example,Supplemental Security Income
Payments for March are paid in March.)
Type of Supplemental Security Income Payment Information
You are entitled to monthly payments as a disabled individual.
Date of Birth Information
The date of birth shown on our records is August 06, 1982.
Medicare Information