HomeMy WebLinkAboutDisability_Hall (2)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
COUNTY
TOWNSHIP
YEAR
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)
Telephone Number
Email Address
Is Applicant the Sole Legal or Equitable Owner?
0Yes ❑ No
If No, What is the Applicants 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 Seller (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 ❑ No
Is Applicant Disabled and Unable to Engage in Any Substantial Gainful Activity?
U Yes ❑ No
Is the Property Used and Occupied Primarily for His/Her Residence?
❑Yes ❑ No
Taxing District
Key Number/ Legal Description
a�-�a-lg-�3-ocx�,� -oag
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
Address of Applicant (number and street city, state, and ZIP code)
L17670
Signature of Authorized Representative
Address of Authorized Representative (number and street, city, state, and ZIP code)
RECEIPT FOR APPLICATION FOR CREDIT FOR BLIND / DISABLED PERSONS
Name of Applicant Dale Filed (month, day, year)
Name of Contract Seller
Taxing District
Key Number / Legal Description
Signature of County Auditor
FILED
MAY 0 7 2026
Date Signed (month, day, year)
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: August- 12, 2024
B N C#': 24M S 720B 05916-HA
I�I�I�I��IIIIII��II�I�I����IIIJII1�1111 f I. I���IIIII
0000191 00025402 2 MB 0.622 0808M3MCS6PI T172 P15
KAREN S HALL
405 E OHIO ST
PRINCETON, IN 47670-3025
You are entitled to monthly disability benefits beginning March 2024.
The Date You Became Disabled
We found that you became disabled under our rules on September 19, 2023.
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 March 2024.
What We Will Pay And When
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 $2,225.00 around August 13, 2024.
• This is the money you are due for March 2024 through July 2024.
• Your next payment of $1,614.00, which is for August 2024'will be ®R
received on or about the fourth Wednesday of September 2024.
• After 'that you will receive $1,614.00 on or about the fourth Wednesday
of each month.
• These and any future payments will go to the financial institution you
selected. Please let us know if you change your mailing address, so we
can send you letters directly.
Other Social Security Benefits
This benefit is the only benefit you can receive from us at this time. In the
future, if you think you might qualify for another benefit from us, you will
need to apply again.
Enclosure(s):
Pub 05-10153
c See Next Page