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Disabilty_Marion Reset Form 1 d;` 4, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR , -0--- DEDUCTION FROM ASSESSED VALUATION State Form 43710(R14/9-24) 3Q7 DO et U 2 leie 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 fled 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 Name of ' nt(owner or contr er) ctry,o‘r, . , Is applicant the sole 16 or equitable owner? If No,what is higher exact share or interest? If owned with someone other than spouse,indicate with whom ❑Yes 0 No If name on record is different than that of applicant,indicate bel ' s' Name of Contract Seller JUL a 12025 Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question: A.diada. piriA.414) ❑Real Pro e ❑Annually Assessed oYA�fp1TOR Property Mobile Home(IC 6-1.1-7) Is applicant blind as defined in IC 12-7-2-21(1)? G( SON Wa ant disabled and unable to engage in any substantial gainful acitty as defined in IC 6-1.1-12-11(d)? ❑Yes 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 ye r e eed$17,000? Yes ❑No ❑Yes ko Taxing District Key Number I Legal Description Record Number(contract) Page Number(cct) o O :30 —000 NO INVe certify under penalty of perjury that the above and foregoing information is true and correct. Sign re of Applican Address of Applicant(number and street,city,state,and ZIP code) _ 2\1 y . 1.3, ignature Authorized epresentative Address of Authorized Representative(number and street,'city,state,and ZIP code) //U "{ O cl r'� Social Security Administration Hill Benefit Verification Lettertt ^� �„isTv..- • 0 ‘.4>s,..4: td I n I II1I IIIiilIriIIIhiIIIIIIInIIIIIIIIu1111114llillillicl BELLY RUSSELL MARION .10 N 213 S 3RD AVEO __ o HAUBSTADT IN 47639-8223 " w �� 0 o�eso� ?©�f You are entitled to monthly disability benefits. 1 See Next Page