Disabilty_Boyle (2) Reset Form
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"� APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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t V DEDUCTION FROM ASSESSED VALUATION C2) t
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Prescribed bythe De artment of Local Government Finance
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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 contract buyer)
O__ 0--C__
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Is applicant the sole I I or uitabl ner? If f hat is his/her exact share or interest? If owned with someoneotherthan� spouse, indicate with whom
Ayes ❑ No
If name on record is different than that of applicant, indicate below:
Name of Contract Seller
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Address of Contract Seller (number and street, city, state, and ZiP code) Is the Property 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 unable b engage in any substantial gainful activity as defined inn IC 6-1.1-12-11(d)?
❑ Yes XNo (, 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?
Yes ❑ No ❑ Yes XNo
TaxingDistrict KeyNumber/Legal Description Record eg p Rico d Number(contract) Page Number(contract)
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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)
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Signature of Auth' -ed ' presentative v Address of Authorized Representative (number r
9 1i� p and street, city, state, and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND / DISABLED PERSONS
Name of Applicant Date Filed pi ar) ED
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Name of Contract S r
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Taxing District ,..,(1--,'\--k-ii`t•-___Z J.--A.C .k_ , (7)24e‘,/z4L1 ��
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Key Number/Legal Description /� GIBSON COUNTY AUDITOR
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Signature of County Auditor Date Signed (month, day, year)
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Notice of Award
Mid-America Program Service Center
601 East Twelfth Street
Kansas City, Missouri 64106-2817
Date: August 30, 2021
BNC#: 21MS492J71781-HA
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0000064 00021627 2 MB 0.485 OR26M3MCS6PI 'I'144 P16
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N GREGORY C BOYLE
1125 DARWIN AVENUE o
PRINCETON, IN 47670-2811
You are entitled to monthly disability benefits beginning November 2021.
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