Disabilty_Collins •
.0-44 APPLICATION FOR BLIND OR DISABLED PERSON'S •
-- UNTY TOWNSHIP YEAR
�, .,_t' ii A. DEDUCTION FROM ASSESSED VALUATION ,
1, , f-' .1)2Q3
31�� ' , State Form 43710(R13/1-20) 1
Sal! Prescribed by the Department of Local Government Finance
J File
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. DECMark
2020
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 and signed by December 31 and filed or postmarked by the following Janua th r year-in which the
property taxes are first due and payable. GIBBON CO
See reverse side for additional instructions and qualifications. U�1TY AUDITOR
Name of applica owne or contra:t u er)
OY CtCLVAA
s applicant the sole legal o equitable owner? If No,what is his/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:
Name of contra t seller
CL
Address of con act seller(number and street,city,state,and ZIP code) I t property in question:
eal Property '❑Annually Assessed
TTTTTT"'''' Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled end unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑ Yes No ❑Yes Elmo
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 El Yes ❑ No
Taxing district 1 Key number/Legal description Record number(contract) • Page number(contract)
V d to /a-o )-/b3-000. /ba-b ag
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)
�2� Q . ' , 6
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
We will withhold_$140,70 from your next check. This check is the money you,
are due through November 2020.
What We Will Pay ,
We pay Social Security benefits for a given month in the next month. For
example, Social Security benefits for March are paid in April.
• Your first payment is for $1,266.30.
• This is the money you are due through November 2020.
Enclosure(s):
Pub 05-10153
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