Disabilty_Stephens •
�E=^;• APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
a _ DEDUCTION FROM ASSESSED VALUATION
1 State Form 43710(R13/1-20)
(/^16Soiri ?c;nctf•vt 4?3
;a a Prescribed by the Department of Local Government Finance �+
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 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.
4041t '3.05e,fh &-cp) e.,16
Is appi cant 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:
Wes ❑ 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 property in question
[3eal Property ❑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 E1 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 S17,000?
Yes ❑ No ❑ Yes [}'No
Taxing district Key number I Legal description Record number(contract) Page number(contract)
c•,nC2A -Ps'07- 0 WO' os'?—001E
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)
Sad 5 Seth c\v-q 5 t- on u_it, \.JJ 404
Signature of authorized presentativ Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day year)
1
r) .\\%aVV% 05P41 S}erJteh 5 FILED
Name of contract seller
AUG 2 2 2023
Taxing district
?( (Nce-ko h Yh,../ziu, a Lic ;na)
Key number/legal description GIBSON COUNTY AUDITOR
—Ia—b7— t63 -bcD. bs-7 r-oD
Signature of County Auditor Date signed(month,day,year)
ERE Amn = Social Security Administration
NEE
Benefit Verification Letter
to
1111
ROM
IMO
c
111111111111IIIIIIII.IsI.II,IIIiii 1111I'I1111i111l1"11l111$"
WILLIAM JOSEPH STEPHENS
- APT 263
t• 702 E MULBERRY ST
PRINCETON IN 47670-2543
You are entitled to monthly disability benefits.
d4i2-00-19_A/3 b*L--A40,1 Cj4/-43 -6 P(i •
See Next Page