Disabilty_Lewis .<!,«fr• . APPLICATION FOR BLIND OR DISABLED PERSON'S
0 A_ COUNTY TOWNSHIP YEAR It. DEDUCTION FROM ASSESSED VALUATION
,. 4 State Form 43710(R13/1-20) 6 i b 5Del sr? F/8-#.,„J, Pc2
..... ,,,,..-, 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 County Auditor of the county where the property is located.
Filing Date: Form must be completed and signed by December
See reverse side for additional instructions and qualifications-
Name of plicant(owner or c tract buyer)
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Is plicant the sole le r equitable owner? If No,what is his/her exact share of interest'? If owned with someone other than spouse,
4 [11 No ff ho
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If name on record is different than that of applicant,indicate below:
FEB 2 2 2022
Name of contract seller
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GIBSON COUNTY AUDITOR
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
D Real Property jj:/"Kr[nually 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)?
EI Yes [?r-No ER-S'es El No
Is the property used and occupied primarily for his/her residence'?
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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)
h/ EiterjOrA. 1-4—'-3° / 5 V r...51. FA Sc-c-06J) ./-iv 9761/es-
gn u o authorized representative Address of authorized representative (number and street,city,state.and ZIP code)
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Social Security Administration
SA
■1I Benefit Verification Letter
Date: February 21, 2022 b
BNC#: 22GL242J55995 y
REF: A
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JEFFREY ALAN LEWIS
304 S VICTOR N
FT BRANCH IN 47648-1531 N
We found that you became disabled under our rules on January 12, 2018. Or