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APPLICATION FOR CREDIT AGAINST PROPERTY
TAXES FOR BLIND OR DISABLED PERSON
State Form 43710 (R15 / 7-25)
Prescribed by the Department of Local Government Finance
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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)
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Telephone Number
LoLcl LA a .
Email Address
Is Applicant the Sole Legal or EquiLaMe Owner?
I'Yes ❑ No
If No, What is the Applicant's Exact Share or Interest?
If Owned with Someone Other than Spouse, Indicate with Whom
If Name on Record is Different than that of Applicant, Indicate Below:
Name of Contract Seller
Address of Contract Seiler (numberand street city, state, and ZIP code)
Is the Property in Question:
[Real Property ❑ Mobile Home (IC 6-1.1-7)
Is Applicant Blind (as defined in IC 12-7-2-21(1))?
❑Yes Milo -
Is Applicant Disabled and Unable to Engage in Any Substantial Gainful Activity?
[�'�es ❑ No
Is the Property Used and Occupied Primarily for His/Her Residence?
es ❑ No
Taxing District �q
Key'Number/ Legal Description
Record Number (contract)
Page Number (contract)
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant
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Address of Applicant (number and street, city, state, and ZIP code)
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SI n Lure of AuthodzedfRepresentdve
Address of Authorized Representative (number and s ity, state, and g code)
RECEIPT FOR APPLICATION FOR CREDIT FOR BLIND / DISABLED PERSONS
Name of Applicant
Date Filed (month a ,Villal
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Name of Contract Seller
MAY 18 2026
Taxing District
Pam-
GIBSON COUNTY AUDITOR
Key Number/ Legal Description
Signature of County Auditor
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Date Signed (month,, day, year)
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Social Security Administration
_ Retirement, Survivors and Disability Insurance
Notice of Award
Mid -America Program Service Center
601 East Twelfth Street
Kansas City, Missouri 64106-2817
Date: December 26, 2023
BNCA 23MS695J19164-HA
JAMES M PAYNE
1806 W CAMBRIDGE PL
PRINCETON, IN 47670-9331
You are entitled to monthly disability benefits beginning April 2023.
The Date You Became Disabled
We found that you became disabled under our rules on October 12, 2022.
To qualify for disability benefits, you must be disabled for five full calendar
months in a row. The first month you are entitled to benefits is April 2023.
What: We .)Vill gay :And Wher
We pay Social Security benefits for a given month in the next month. For
example, Social Security benefits for March are paid in April.
• You will receive $8,076.00 around .December 26, 2023.
• This is the money you are due for April 2023 through November 2023.
• Your next payment of $1,389.00, which is for December 2023, will be
received on or about the second Wednesday of January 2024.
• After that you will receive $1,389.00 on or about the second Wednesday
of each month.
• Later in this letter, we will show you how we figured these amounts.
• New rules require you to receive your payments electronically, unless
you get an exemption from the U.S. Department of the Treasury. Please
call Treasury at 1-888-224-2950 to see if you qualify for an exemption.
Enclosure(s):
Pub 05-10153
Pub 70-10281
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