HomeMy WebLinkAboutDisabilty_Robinson •
¢ zT . APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION �—/
State Form y the epaR13/1-20) _ &1 Q
sS� �' Prescribed by the Department of Local Government Finance ��/r\(r V
File Mark
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 and signed by December 31 and filed or postmarked by the following January 5 of the calendar year in which the
property taxes are first due and payable.
�
VL-*()J•J'M'- V %1\ (KC:DV _
I icant the sole legal ore ita le owner? If No,what is his/her exact share ofhinterest? If owned with someone other than spouse.
indicate with whom:
Yes ❑ No FILE
If name on record is different tha hat applicant,indicate below:
Name of contract seller NOV'V 20�1
,yd..0 a,-147 4.r.e.)
Address of contract seller(number and street,city,state,and ZIP code) GILT,;ON COUNTY AUDITO t property in question:
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 una►le to gage 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 cale ar ear
exceed$17,000?
X
Yes CI No El Yes No
Taxing district
K. Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
; �--�C� __.� ,' q, � � � O\ lan a G- -o Y)
Signature of authorized representative \' ' Address of authorized representative (number Jd street,city,state,and ZIP code)
a,
Social Security Administration
Retirement, Survivors and Disability Insurance
'crOtice of A.ward�
// Mid-America Program Service Center
601 East Twelfth Street
Kansas City, Missouri 64106-2817
Date: February 13, 2017
Claim Number: 305-76-9578HA
IIIIduI.,u4iuuIuI41uIIIItIIIIIIIIIIIIuIIIIIIuIu.ripuuIIriI
509 2 M$0.423 T4 MAAD296 PL1 S296 M3 PC6 170209
ro