Disabilty_Cousert (2) 6rr"=•, APPLICATION FOR BLIND OR DISABLED PERSON'S C UNTY TOWNSHIP YEAR
d:/-} � DEDUCTION FROM ASSESSED VALUATION
_ ",. State Form 43710(R13/1-20)
'�eie`/� Prescribed by the Department of Local Government Finance /bj Iat C-.t-/ CJ G
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 uyer)
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Is applicant the sole legal or equitabl owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
Yes ❑ No
If name on record is different than that of applicant,indicate below:
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) th 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)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑ Yes ❑ No �/'Yes El No
Is the property used and occupied primarily for his/her residence? Does'the applicant's taxable gross income for the preceding calend r y r
exceed$17,000?
❑ Yes ❑ No ❑Yes�No
Taxing district Key number/Legal description Record number(contract) ` •Page number(contract)
gig(A:frOl Z ?t0,05-Aar-�. /38-e j,
I/We certify under penalty of perjury that the above and foregoing information's true and correct.
Signature of applicant Address of applicant (number and street,city,state, nd ZIP code)
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ignature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day,year
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Name of contract seller
__ SEP 2 2020
Taxing dis 'ct
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number/le aldescri description IBSON COUNTY AU�� G�
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Sign e of County Auditor Date signed(month,day,year)
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