Disabilty_Young ,; *,,, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
A. '`;:. �;,, DEDUCTION FROM ASSESSED VALUATION
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to1 i State Form 43710(R13I 1-20)
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a„� 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
property taxes are first due and payable.
See reverse side for additional instructions and qualifications
Name of applicant(owner or contract buyer)
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Is applicant the sole legal or equitable owner? l No.what is his;her exact share of interest? If El LErDous
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indicate with whom:
❑ Yes ❑ No JAN12 2024_If name on record is different than that of applicant,indicate below.
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Name of contract seller GIBSON COUNTY AUDITOR
Address of contract seller(number and street,city,state,and ZIP code) s th r perty in question.
Real 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 able to gage in any substantial gainful activity
as defined in IC 6-1 1-12-11(d)?
— Yes No , es ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calen ar year
exceed si7,000?
Yes ❑ No ❑ Yes No
Taxing district 0 .
2..zy Key n be 1 Legal description Record number(contract) Page number cone ct)
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IIWe certify under penalty of perjury that the above and foregoing information is true and correct.
gnature of applicant
XgCAddress of applicant (number and street.city.state,and ZIP code)
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re oo authonz representative Address�off authorized representative (number and street,city,state.and ZIP code)
Social Security Administration
Retirement, Survivors and Disability Insurance
Notice of Award
Mid-America Program Service Center
601 East Twelfth Street
Kansas City, Missouri 64106-2817
Date: January 2, 2024
BNC#: 24MS713C44109-HA