Disabilty_Stewart ��;^;•� APPLICATION FOR BLIND OR DISABLED PERSO y IJ F TOWNSHIP YEAR
�„ - � -�-.J
81 y.. DEDUCTION FROM ASSESSED VALUATION
" State Form 43710(R13/1-20) DEC 2 8 2o2P sow (o rLo2-"'*` •1 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.
GIBS X4
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county wlt�rc�&QFblYe fb • `:-d.
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.
Nameme of applicant(owner or contract buyer)
Is app'icant the sole legal or equitab e owner's If No,what is his.'her exact share of interest' it 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
Address of contract seller(number and street.city,state.and ZIP code) Is the property in question
[ Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Is a d as defined in IC 12-7-2-21(1)n Is applicant disabled and unable to engage in any substantial gainful activity
,��// as defined in IC 6-1 1-12-11(d)?
❑ Yes No Yes El No
A the prope and occupied primarily for his/her residences Does the applicant's taxable gross income for the preceding calendar year
exceed S17,000"
<es ❑ No ❑ Yes ❑.No
Taxing�rict Key number/Legal description Record number(contract) Page number(contract)
aG-oy- a5 _lai - 0oo, aa '7-o � 0
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of:applicant ddress of applicant (number and street,city state.and ZIP code)
/ ,,,1 `•f 011 cN 3(4 ST P ±N 't`2&6&
Signature representative r Address of authorized representative (number and street,city,state.and ZIP code) -
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of Japplicant Date filed(month,day year)
Name of contract seller
Taxing di •ct
6/ 120t) aleti- )—
Key number I legal description
o76 -o'j- aS -iol - 000• a ' 7 - oxO
Signature of County Auditor Date signed(month,day.year)
, ■ .
Type of Supplemental Security Income Payment Information
You are entitled to monthly payments as a disabled individual.
Date of Birth Information
$A,,,,, Social Security Administration
` Iiiuo �e Benefit Verification Letter
cD
`Nts *5 a
Date: December 5, 2023
BNC#: 23GV273A66110