Disabilty_Caswell �,. \, APPLICATION FOR BLIND OR DISABLED PERSON'S I:II:ED
YEAR
y;;. DEDUCTION FROM ASSESSED VALUATION
N' i' State Form 43710(R13/1-20)
.a Nag)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. APR 1Fle2011
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located.7', /�
Filing Date: Form must be completed and signed by December 31 and filed or postmarked by the follow ugrOaG[1�gcc�6f4 r in which the
property taxes are first due and payable. GIBSON COUNTY AUDIT
See revers ' e for additional instructions and qualifications.
Name of applic t(owner or contract b
uyer)
r/� f/nD
/// /-�t/�{Is applica a sole legal or equier? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
jSLYes ❑ No
If name on record is different than that of applicant,indicate below,
Name of contract seller )
,� !__ o / /_5- 9 _/��c
A.0 o act seller(nu r and street,city,state,and ZIP code) g property in question:
Real Property El 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 No "Yes ❑ 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 ❑ No 0 Yes No
Taxing district Key number/L al description Record number(contract) Page number(contract)
`s,/.)Qd , aT ald/; =/o,-Qa .G..17 DaaZ.,
I/We certify der f enalty •f 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)
Signature of authorized representative Address of authorized representative (number and street,city,store.and ZIP code)
7,. � ��SOCIAL SECURITY ADMINISTRATION
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11. The claimant has been under a disability, as defined in the Social Security Act,from
November 9, 2005 through the date of this decision (20 CFR 404.1520(g) and 416.920(g)).
DECISION
Based on the application for a period of disability and disability insurance benefits filed on
_ November 9, 2005,the claimant has been disabled under sections 216(i) and 223(d)of the Social
Security Act beginning on November 9, 2005.
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