Disabilty_Kelley Reset Form
e `."4 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
x :- DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R1419-24) //�,,twrl� r
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'oo Prescribed by the Department of Local Government Finance
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 the calendar year in which the property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Name of Applicant(owner or contrac bu r)
44-4 FILED
Is appli nt the sole legal or equitable owner? I o,what is his/her exact share or interest? If owned with someone other than spouse,indicate with whom
Yes 0 No APR 15 1025
If name on record is different than that of applicant,indicate below:
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G1esOfV COATI,a y4
Name of Contract SellerAUD'`
0rt
Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question:
Real Property 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)?
❑Yes ANo *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$17,000?
es 0 No EYes 0 No
Taxing District Key Number/Legal Description Record Number(contract) Page Number(contract)
0 AS IRA/7rada 4a -69'
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant Address of Ap ' ant(number and street,city,state and ZI de)
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llliGETDA) ‘L767
Signature of Aut ed Represe ativ Address of Authorized Representative(number and street,city,state,and ZIP code)
lir IA
G`z1,S ECoRi N
t Social Security Administration
ulllu o Benefit Verification Letter
You are entitled to monthly disability benefits.
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