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Disabilty_Kerstein , �f-,-7Q,,.: APPLICATION FOR BLIND OR DISABLED PERSON'S UNTY TOWNSHIP YEAR =a DEDUCTION FROM ASSESSED VALUATION ',�� ' State Form 43710(R13/1-20) lit) /� Prescribed by the Department of Local Government Finance V �� , 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 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. Name o? t/ - Is nt(owner or contract buyer) applicant the sole legal or uitable owner? 1 If No,what is his/her exact share of interest? If owned with someone other than spouse, indicate with whom ❑ Yes lit No -�f l.. e/I—e- / If name on record is different than that of applicant,indicate below: /_"K� 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(I 6-1.1-7) Is applicant blind as defined in IC 12-7-2-21(1)2 Is applicant disabled and unable to engage in any substantial ga. ful acti 'y as defined in IC 6-1.1-12-11(d)? ❑ Yes y No Yes ❑ No Is the property used and occupied primarily for his/her residence') Does the applicant's taxable gross income for the preceding calendar y ar exceed S17,0002 IX Yes ❑ No ❑ Yes KNo Taxing 'strict -�oo Key number/Legal description Record number(contract) Page number(contract) G%trru0-) a (-!!-i S. /a -ao% 7! 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) 1 Z 2p j4tiii2=s1_1/4.4.7) 1 9 / -5, le9 1:d-e c- )(-19'4--cil IV iLc_ ini 1 AZ1S ignature of authorized representative Address of authorized representative (number and street,city,state.and ZIP code) RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS Name of applica Date filed(month,day year) Name of contracts e-7,- FILED JUN 04 2024 Taxing dis/ ' l!i2frief'.-) NV- (j-f) G .OUNTY AUDITOR Key number/legal description a - // -/ $ - i / , ©off . 7 /! -0a7 Signature of County Auditor Date signed(month,day,year) )61, 1e-e_/144.0 4,_..4",---- (....)1> 03tn bll M6 Social Security Administration Retirement, Survivors, and Disability Insurance Notice of Award Mid-America Program