Disabilty_King A.
STA. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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a DEDUCTION FROM ASSESSED VALUATION r,
;` I State Form y the epa/1-20) , ` f--{t` _ ''''() Cc 7 �?2
' = Prescribed by the Department of Local Government Finance VrT`�/t1l/� r
�p ^1 ' File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. 1 V':v[�.
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where t e property is located.
Filing Date: Form must be completed and signed by December 31 and
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Is applicant the sol leg I or equitable ow r? If o, hat is his/her exact share of�sT T `_J I w with someone other than spouse,
l■1■ L lrl � ica with whom:
El Yes El No 8
If name on record is different than that of applicant,indicate below: MAR
` 0 2022
Name of contract seller !I h.,,,,7.Q.4C a. J{ldz r,
GIBSON COUNTY AUDITOR
Address of contract seller(number and street,city,state,and ZIP code) I the 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 unable to engage in any substantial gainful activity
///""" as defined in IC 6-1.1-12-11(d)?
El Yes L,�No Yes [1] No
Is the property used and occupied primarily for his/her residence? / \ Does the applicant's taxable gross income for the preceding Galen ar ear
exceed$17,000?
Yes ❑ No ❑ Yes No
Taxing district Key nu be /Legal description Record number(contract) Page number( nt cf)
On - 26- i I -I S`--(co --00I 093-02q- -
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)
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`-ignature oii orized representative 411.1r Address of authorized representative (number and street,city,state,and ZIP code)
Social Security Administration
Retirement, Survivors and Disability Insurance
Notice of Award
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0000598 00067647 2 MB 0.439 0106M3MCS6PI T561 P20
�.- WAUGHNETA G KING
i243`• 3052 W 50 S
PRINCETON, IN 47670-8129
You are entitled to monthly disability benefits beginning January 2021.
The Date You Became Disabled
We found that you became disabled under our rules on July 6, 2020.