Disabilty_Toth • „ ;,.. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
11 ' s, State Form 43710(R13/1-20) Gson 026 2021
5 « Prescribed by the Department of Local Government Finance
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
"� 3Name of applicant(owner or contract buyer) \
Christine Marie Toth
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:
❑ Yes El No
If name on record is different than that of applicant,indicate below: T I.L E L/■11
Name of contract seller 1. DEC 2 9 202
Address of contract seller(number and street,city,state,and ZIP code) ki G-� �'U4.'-- "" Is the property in question:
GIBBON COUNTY rN1i0170R ® 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 unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
® Yes m No ® Yes El 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 Cl No ❑ Yes 10 No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
026 26-18-24-202-001.377-026
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
x •
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
210 E Spruce St, P'ton, IN 47670
Signature represe tive Address of authorized representative (number and street,city,state,and ZIP code)
• Christine Marie Toth (316-82-1 178) Page 4 of 4
).
DECISION
Based on the application for supplemental security income protectively filed on December 12,
2019, the claimant has been disabled under section 1614(a)(3)(A) of the Social Security Act
since December 12, 2019.
.
/s/A tthia Vndeftah.
Matthias Onderak
Administrative Law Judge
September 10, 2021
Date
0005390 00012269 1 MB 0.485 SN6LNA T57 P4
SSI MA2 10/28 457 21S1620B78364
•' - CHRISTINE MARIE TOTH
300 S MAIN ST
FORT BRANCH IN 47648-1512
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SSA-L8165
Notice of Award
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0003778 00003778 3 MB 0.485 SI6LNA T23 P1
SSI M06 10/26 457 21S1620B78364
- CHRISTINE MARIE TOTH
300 S MAIN ST
FORT BRANCH IN 47648-1512