Disabilty_Bockhold ,4-.4, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY I TOWNSHIP YEAR
__ em; DEDUCTION FROM ASSESSED VALUATION
91 State Form 43710(R13/1-20)
Gibson 028 2020
"',,„--- ' Prescribed by the Department of Local Government Finance
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)
Mike Bockhold f i - �
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owne., i i al e 5 --e oth�- -'n .=,
indicat= 'th 1. i__.,,
I] Yes ❑ No Contract- Pat Vanoven
If name on record is different than that of applicant,indicate below: O C T 1 9 2020
Name of contract seller
and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑ Yes Ij No 0 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$17,000?
II Yes ❑ No ❑ Yes IL] No
Taxing district Key number I Legal description Record number(contract) ' Page number(contract)
028 26-12-07-201-000.013-028
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of a licant Address of applicant (number and street,city,state,and ZIP code)
X423 E Glendale, P'ton, IN 47670
Si n- authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
1'
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.
• Later in this letter, we will show you how we figured these amounts.
• The day of the month you receive your payments depends on your date
of birth.
Enclosure(s):
Pub 05-10153
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