Disabilty_Hale (2) .��:t-rQ,„ APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
'Y % ,4 DEDUCTION FROM ASSESSED VALUATION
rt ( ) +0AC) 'U`�.4- 2-,22�` !Zi' State Form 43710 R13/1-20 I
\ ''' 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 31 and filed or postmarked by the following January 5 of the calendar year in which the
property taxes are first due and payable. LA - a ^_a"�_ 9�� �Q f
See reverse side for additional instructions and qualifications. O�l�Sl ^, k�
V.
Name of applicant(owner or contract buyer) (�
•
Is applicant the sole legal or equitable owner? If No,what is his/
whom:
Yes ❑ No
If name on record is different than that of applicant,indicate below:
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the pr 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)?
❑Yes ❑ No Er-CI:-
❑ 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? ,�(
es ❑ No Er Yes No
Taxing ' trict Key number/Legal description Record number(contract) Page number(contract)
7704-5 /0 2 -a- 7g=349-- 119/- 7®8 oa 7
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
IP code)
X_g:}e2A — �7cf LS' /7 �', �ro--(7 -► g71o7D
Signature of representative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day.year)
��1 -beZ� 2 qV` FILED
Name of contract seller
Taxing distrriicctt//t APR 2 2 2022
G 1Vn(//� /� �-f]�
Key number/legal description 0 GIBSON COUNTY AUDITOR' II
2ZP -/2--�8- - CO) - 705- �' 27 UU
Signature of County Auditor �p�(' A__ Date/�signed
7(month,day,year)
'fi/i.N/I7 CQ'�l ter/.-? / /L z_/z(/
(i(Xir l
Your New Benefit Amount •
BENEFICIARY'S NAME: ELIZABETH C HALE
Your Social Security benefit will increase by 5.9%in 2022 because of a rise in the cost of
living. You can use this letter as proof of your benefit amount if you need to apply for food,
rent,or energy assistance. You can also use it to apply for bank loans or for other business.
Keep this letter with your important financial records.
How Much You Will Get
Your monthly benefit before deductions $1,428.10
Deductions:
Medicare Medical Insurance(If you did not have Medicare as of November 18, -$170.10
2021 or if someone else pays your premium,we show$0.00)
Medicare Prescription Drug Plan(We will notify you if the amount changes in -$0.00
2022. If you did not elect withholding as of November 1,2021,we show$0.00)
U.S.Federal tax withholding -$0.00
Voluntary Federal tax withholding(If you did not elect voluntary tax -$0.00
• withholding as of November 18,2021,we show$0.00)
After we take any other deductions,you will receive $1.2 5 8.0 0
• the payment you are due for December 202bn or about January 19, 2022.
The information above shows your monthly benefit amount before and after deductions.
Please remember,we will pay you in the month following the month for which it is due.
The Treasury Department requires Federal benefit payments to be made electronically.
If you still receive a paper check,please visit the Department of the Treasury's Go Direct
website at www.godirect.gov to request electronic payments.
If you disagree with any of these amounts,you must file an appeal with us within 60 days
from the date you receive this letter. We will assume you got this letter 5 days after the date
of the letter,unless you show us that you did not get it within the 5-day period. The fastest
and easiest way to file an appeal is to visit https://secure.ssa.gov/iAppLNMD/start online.
If You Have Questions
• Visit us at www.ssa.gov online.
• Call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
• Contact your nearest Social Security office.
2300 N GREEN RIVER RD
EVANSVILLE IN 47715
Other Help For Older Adults and People with Disabilities
The Administration for Community Living offers older adults and people with disabilities
a way to connect to a variety of community services and resources.
For Older Adults: Eldercare Locator at 1-800-677-1116 or www.eldercare.acl.gov