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Disabilty_McIntosh .,„Errs.\, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR 1 c '= `'y DEDUCTION FROM ASSESSED VALUATION 23 ' ', State Form 43710(R13/1-20) ''° Prescribed by the Department of Local Government Finance O2- I6I 2�Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark 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 Name of applican er or contract buyer) nqo\ _ VI ct*-3 A Is applicant the sole egal 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 If name on record is different than that of applicant,indicate below: Name of contract seller '�/� 1\.1 -7. "� ')C) Address of contract seller4), reet,ci IP,an codgy f th property in question: h Real Property ❑ Annually Assessed AA,© YA Mobile Home(IC 6-1.1-7) Is applicant blind as defined in IC 12-*Q1(1)? Jet Is applicant disabled and unable to ngage in any substantial gainful activity /],_ '°' as defined in IC 6-1.1-12-11(d)? i ,.. J� ❑ Yes o Yes ❑ No Is the property used and occupied prima i 04 residence? Does the applicant's taxable gross income for the preceding eaten r ear 4) exceed$17,000? C, es ❑ No ❑ Yes No Taxing district Key num r/ gal description Record number(contract) Page number(6ont`act) o - Z 6 - 1 -01 -2�1-000 .0-2.i1- 3. I/We certify under penalty of perjury that the above and foregoing information is true and correct. Signature of applicant Ad ss of ap licant (number and street,city,state,and ZIP cod )( an/net Mid .../ —LpV)—\.11%1-0 Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code) RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISA D P ill 6 Name 'cant le i(month,day,year) A Qillq k_ 0/1 c_jv) -tas \ ` Name of ract seller ,..... ........., 1 Taxing district /) vO�(OR o i " CX � ��"� Key number/leg description G 2.---- P--\2rC71- 1 - 0oO. 021 c2g . Signature of County Auditor Date si ed(month,day,year) Notice of Award SOCIAL SECURITY 2300 N GREEN RIVER RD EVANSVILLE IN 47715 0 Date: September 25, 2020 BNC#: 2051962D12949 DI 0 0 0 0 SSI as of May 2019 based on being disabled. See Next Page SSA-L8025