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Disabilty_Schafer �;�, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHt;— YEAR ; � DEDUCTION FROM ASSESSED VALUATION ram: State Form 43710(R12/10-16) 1,614A,�� teas Prescribed by the Department of Local Government Finance v, Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. 2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12)months before March 31 of each year the individual wishes to obtain the deduction. See reverse side for additional instructions and qualifications. Name of applicant(owner or contract b r) (n�11 \ c"1 • SC \ eA. . Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse, indicate with whom: es ❑No If name on record is different than at of plicant,indicate below: Name of contract seller ED • Address of contract seller(number and street;city,state,and ZIP code) FEB 2 5'2020 I 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)? GIBSO+N C wt./ U d Plicant ned in IC bl d and-unable to a age in any substantial gainful activity Iv-TyUg� (d)? rOR ❑Yes ❑No D 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 xYe exceed$17,000? s ❑No les ❑No Taxing district Key number/Legal description Record number(contra ) Page number(contract) 4- ID 0012.- 0,6 197 I/We certify under penalty of perjury that the above and foregoing information is true and correct. Signature of applicant Address of applicant (nu berand street,city, ate,and ZIP code) Signature of authorized representative Address of authorized representative (number and street,city,lstate,and ZIP code) • This is the money you are due through August 2018. • Your next scheduled payment of $2,097.00, which is for • September 2018, will be received on or about the third Wednesday of October 2018. • After the first payment, you will receive $2,097.00 on or about the third Wednesday of each month. Your monthly payments will go to the financial institution you selected. SEE NEXT PAGE