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Disabilty_Smerchek �j .Reset�Folrrri (,0"e4. APPLICATION FOR BLIND OR DISABLED PERSON'SCOUNTY TOWNSHIP YEAR 40-'- t DEDUCTION FROM ASSESSED VALUATION State Form 43710(R14/9-24) v �•• tOl Prescribed by the Department of Local Government Finance �mbla� 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,signed,and filed by January 15 of CA eon _ S rs\ Is applicant the sole legal or quitable owner? If No,what is his1 er exact share or interest? If owned with someone other than spouse,indicate with whom Pe. ❑No If name on record Is different than that of applicant,indicate below: Name of Contract Seller \ ll Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question: 1134operty 0 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)? 0 Yes `lX 0 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$17,000? es ❑No ❑Yes WK.'. Taxing District Key Number/Legal Description Record Number(contract) Page Number(contract) 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) A(ijsA kaao 100-1wewaL9-t- i-tiu2kkro, Signature of Authorized Representative Address of Authorized Representative(number and-btreet,city,state,and ZIP code) RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS Name of Applicant Date Filed(moot y LED Name of Contract Seller APR 0 2 2025 Taxing District 1 Y Ac aAi Key Number/Legal Description GIBSON COUNTY AUDITOR �Q-( a -'QC)-COO . ,okket- \Siign�aturree of County Auditor n Date Signed(month,day,year) C G`Py SECG� o °�USa��` Social Security Administration 9d 11uui o= Benefit Verification Letter p tti N NISTRP 0 td tj c iulliljlllllliiuhlniillillllllhiillihilliililulliuhllulilillPJ CLEAT LEE SMERCHEK o 1320 N 1200E OAKLAND CITY IN 47660-8156 N You are entitled to monthly disability benefits. C See Next Page