Disabilty_Hall 7.04:r hq, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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.: DEDUCTION FROM ASSESSED VALUATION
State Form 43710 (R1311-20i �`
Prescribed by the Department of Local Government Finance Gson OoL
2
File Mark
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 and signed by December 31 and filed or postmarked by the following January 5 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)
Hall, James Randall F se
Is applicant the sole legal or equitable owner? If No, what is his/her exact share of interest? If ow it • o one other than spouse,
i to it ho
Yes ❑ No
If name on record is different than that of applicant, indicate below: UEC 3 n
2025
2,1,,,,i4.44.,
Name of contract seller
GI8GGN . 2 ji
. T Ptif.)1Th;
Address of contract seller(number and street. city, state, and ZIP code) Is the property in question:
IZ 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 to engage in any substantial gainful activity
as defined in IC 641-12-11(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 year
exceed S17,000?
i6Yes ❑ No ❑ Yes ® No
Taxing distnct Key number/ Legal description Record number(contract) Page number (contract)
004 26-05-35-400-001 .813-004
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)
)(i2-- 7144
4473 E 200 N, Pton, IN 47670
Signature of authorized representative Address of authorized representative (number and street, city, state, and ZIP code)
Social Security Administration
Retirement, Survivors and. Disability Insurance
Notice of Award
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0000244 00024827 2 MB 0.672 1120 M 3MC S6 P I T169 P18
- JAMES HALL 8
A- i 4473 E 200 N o
a •
PRINCETON, IN 47670-8934
You are entitled to monthly disability benefits beginning July 2025.
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