HomeMy WebLinkAboutDisabilty_Mossberger �s .2 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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_` . State Form 43710(R13/1-20) ///������!ll...��` �� ��(�2
"���le. Prescribed by the Department of Local Government Finance
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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
Name of applicant(owner or contract buyer
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Is applicant the sole legal or quitable owner? If No,what' is/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑ Yes ❑ No
If name on record is different than that of applicant,indicate below:
Name of contract sel r, T L E D
Address of contract seller E.hbmLeZ,4 ski Zaty,state,and ZIP code) Is the property in question.
1 ❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blip I)3 A` CU7 Is applicant disabled and unable to engage in any substantial gainful activity
C:(JU ITOR as defined in IC 6-1.1-12-11(d).
es , *Jo /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?
es ❑ No ❑Yes Xo
Taxing district
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 of aut orized representative Address of authorized representative (number and street,city,state,and ZIP code)
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.?A- -\‘ Social Security Administration
hilly oz Benefit Verification Letter
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CHRISTOPHER DON MOSSBERGER
605 S 9TH AVE
HAUBSTADT IN 47639-8235 ti
We found that you became disabled under our rules on April 1, 2017.
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