HomeMy WebLinkAboutDisabilty_Comer APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R13/1-20) COS oil a02
Prescribed by the Department of Local Government Finance
Jt 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
Name of applicant(owner or contract buyer
•
Is applicant the sole legal ore it e owner, If No.what is his/her exact share Of interest? If owned with someone other than spouse.
Yfes
indicate with whom.
❑ No
If name on record is different thanpplicant,indicate below•
Name of contract setter
Address of contract seller(number and street.city,state.and ZIP code) IstI 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)7 Is applicant disabled and unable to engage in any substantial gainful activity
• as defined in IC 6-1 1-12-11(d)7 AYes
❑ Yes X No CINo
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calear
• Xes
exceed S17,0007
,`y(,❑No ❑ Yes t� No
• Taxing district Key nuLegal description Record number(contract) Page number(//tract)
0 - X6-1t ^tG�)ioo-003.),-1-k.+- 02fi
IiWe 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)
Stature of authorized representative Address of authonzed representative (number and street,city,state.and ZIP code)
•
•
•
• RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Date (month day year)
Name of applicant
e, C.:3wI \ .
Name of contract seller
Taxing district
Key number I legal description
— I L 9,00 - 00z . aT4
Signature of County Auditor Data s ed(month day.year)
Social Security Administration
— Supplemental Security Income
Notice of Award
SOCIAL SECURITY
rnrn-
See Next Page
SSA-L8025