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'' APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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�� DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R1419-24)
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'it., Prescribed bythe Department of Local Government FinanceS °I\ ' _ OZ) - _
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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
NrorciTicant(owner or contract b r
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Is applicant the sole legal or equita le wQe , If No, what is his/her exact share or interest? ' some a hen spouse,indicate with whom
Yes ❑ No
If name on r cor is different than that of applicant, indicate below: ote
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44,:/Name of Contract Seller G/ ~
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Address of Contract Seller(number and street, city, state, and ZIP code) Is the Property inOtille) id
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A eal 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 to '• in any substantial gainful ad vey as defined in IC 6-1.1-12-11(d)?
Yes I No Ai Yes 7 No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar y::r ex,eed S 17,000?
Yes ❑ No ❑ Yes ' . No
Taxing District ey Number I Legal Description Record Number(contract) Page Number( nt ct)
0 1 - 26) 3° 3a) °D'O . 4 ..--0P25 ,
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
e5ignature of Applicant Address of Applicant (number and street, city, state, and ZIP code)
tel I kJ • I II r ` CItS COO 4) 0)4( e_ n
ture of Authorized Repress t tive A ess of Authorized Representative(dumber and street, city, state, and ZIP code)
Social Security Administration
Retirement, Survivors and Disability Insurance
Notice of Award
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0000214 00027270 2 MB 0.571 0510M3MCS6P1 T190 P18
c ::rN JAMES HOFFMAN 8
. 8594 S 600 W
OWENSVILLE, IN 47665-9312
You are entitled to monthly disability benefits beginning December 2023.
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Pub 05-10153
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