Disabilty_Hartman APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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_ k DEDUCTION FROM ASSESSED VALUATIONI,., `
�1. State Form 43710(R13/1-20) 6, ,J So✓I -50 n Yt�QY1 a C�
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.
See reverse side for additional instructions and qualifications-
�. r ry G
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
[]'Fes ❑ 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 pro rty in question:
eal 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 EQ 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$17,000?
4 '/; ❑ No ❑ Yes No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
Jo�nhsv►n G-, a-► 309--o50. 743a-Da-1
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
I$CXj 51 5 V /10
O . 10_d ;- Zn/ q 7 //,//,��dP a/
ignature authoriz d representative Address of authorized representative (number and street,city,state,and ZIP LtS
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Date filed(month,day.year)
Name oflapp Qlicant
'r V) to (— f./Y�O.✓�
Name of contract seller
Taxing district NEED
Jot, n So v,r DEC 2 9 2022
Key number/legal description
2 6— a -( - 3Ul>-
Signature of County Auditor eilWOR
Social Security Administration
Retirement, Survivors and Disability Insurance
Notice of Award
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LARRY G HARTMAN
1133 SHEFFIELD DR
EVANSVILLE, IN 47710-3817