Disabilty_Burleson �,s, ,, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
7,i,. 4 DEDUCTION FROM ASSESSED VALUATION /�
_f.` to, State Form 43710(R13/1-20) /'�\ / � ��
%''' Prescribed by the Department of Local Government Finance ��I.N. ) C� CC��
.115 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 cated.
Filing Date: Form
must
taxes are completed
d due and
signed
payable.December 31 and filed or postmarked by the following January 5 of the calendar year in which the
p
rty
fi
a
d
See reverse side for additional instructions and qualifications. P g \Z - C.-T7- l)-3 3
Name of applicant(owner or contract buyer)
JQ C__- uvAe_s 0rl
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:
❑ Yes ❑ No FILED
If name on record is different than that of applicant,indicate below:
JAN 1 8 2023
Name of contract seller \mil/_ D y�� /_\(,I/\(\t/J{ //Lcc.iLSLGI_i .i%YY .242
Address of contract seller n and streer,city,state,and ZIP code) GIBSON COUNTY AUDITOR
I-th= •roperty in question:
(• Real Property ❑ Annually Assessed
A Mobile Home(IC 6-1.1-7)
Is applicant blind as`i IC 12-7-2-21(1)2 Is applicant disabled and unable toe gage in any subst- ful activity
as defined in IC 6-1.1-12-11(d)?
❑ Yes Klo \\ Yes Wo
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding Galen•. -ar
exceed$17,0002
es ❑ No ❑ Yes No
Taxing district
Key nurvrvrvrv���er Legal description Record number(contract) Page number ont cf)
0 2E - 2b--- 1 Z-0 6- 3 03 -doh Z— O .
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
gnatu?•f applicant�fr• 2 Address of applicant (number and street,city,state, nd ZIP code)
4 Address of authorized4 prese tive (number and street,city,state and ZIP code)
'S'enature of authorized representative
•
_ x
IMPORTANT INFORMATION
If You Work Or Want To Return To Work
We have a free and voluntary program called Ticket to Work that helps people who get
disability benefits go to work. If you participate in this program, we may set aside
review of your medical condition. Special rules may allow you to keep your Medicare
or Medicaid and some or all of your disability benefits during your transition to work.
Over time, you can replace your benefit payments with earnings from work. Please
visit www.choosework.ssa.gov to find a list of service providers, including benefits
and work incentives counselors, who can help you find, prepare for, and keep a job.
For more information, contact the Ticket to Work Help Line at 1-866-968-7842
(TTY 1-866-833-2967).
If you receive disability benefits and work, you must call us right away at
1-800-772-1213 (TTY 1-800-325-0778) and tell us about any earnings you have. When
you get Supplemental Security Income, you must also tell us each month if there are
changes in the amount of your earnings. If you do not report your earnings and get paid
too much, you may have to repay benefits received. When you report your earnings, we
will give you a receipt to verify your report. Keep this receipt with your other import-
ant papers from us. To learn more, visit w_ww.ssa.gov/pubs/EN-05-10095.pdf and read
Working While Disabled:How We Can Help (Publication No. 05-10095). For information
on employment support programs, visit www.ssa.gov/red book and read The Red Book
A Summary Guide To Employment Supports (Publication No. 64-030).
Easy Ways To Report Wages
Our "myWageReport" tool lets you report wages securely online using a computer, tablet
or smartphone through your my Social Security account.
o.r.to rmvno_Ryn._gJnn/m% g.l)1int to Rut. lin rn1ir at-en-runt.
• Your New Benefit Amount
•
BENEFICIARY'S NAME: JAMES E BURLESON
Your Social Security benefit will increase by 8.7%in 2023 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,re
or energy assistance. You can also use it to apply for bank loans or for other business. Keep
letter with your important financial records.
How Much You Will Get
Your monthly benefit before deductions
- $2,451.00
Deductions: -$0.00
Medicare Medical Insurance (If you did not have Medicare as of November 17,
2022 or if someone else pays your premium,we show $0.00) -$0.00
Medicare Prescription Drug Plan(We will notify you if the amount changes in
2023. If you did not elect withholding as of November 1, 2022,we show $0.00) -$0.00
U.S.Federal tax withholding
Voluntary Federal tax withholding(If you did not elect voluntary tax
-$0.00
withholding as of November 17, 2022,we show $0.00)
After we take any other deductions,you will receive
$2,451.00 I
the payment you are due for December 2022 on or about January 3, 2023.
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
If you still get a paper check, you must visit-the Department of the Treasury's website at
www.godirect.gov to request electronic payments.
If you disagree with any of these amounts, you must file an appeal with us in writing within
60 days from the date you get 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. You must
have good reason for waiting more than 60 days to file an appe
al. You can go to www.ssa.gov/
to complete and submit the"Request for Reconsideration"form, SSA-