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0,--.� APPLICATION FOR BLIN OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
y, '.%- DEDUCTION FROM ASSE N
3 !fy State Form 43710(R13/1-20)
�' ,eie �` 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 prope 9 -'. ei,. 4
Filing Date: Form must be completed and signed by December 31 and filed or postmarked by the f4i owin J-1 ua o h .,.!'ndar year in which the
property taxes are first due and payable.
See reverse side for itional instructions and qualifications. DEC 2 12020
Na of applicant(owner or contract buyer)
C‘C- 0 GI'14 a Lx tI-DaVo
Is applicant the sole le or equitable r? If No,what is his/her exact shalr�of interest? o e use,
�� _ indicate with whom:
Yes Ike _
- `,
Name of contract seller
•
naa- CLA\-t 1,\ _
Address o co act seller(number arid street,city,state,and ZIP code)
Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)7 Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑ Yes I'No lames ❑ No
Is the property used and occupied primarily for his/her residence? Does the applidaht's taxable gross income for the preceding calendar year
exceed$17,000?es —2-VC)...❑ No ❑Yes L71vo
Taxing district Key number/Legal description I Record number(contract) , Page number(contract)
aQ — 11 -1 'CDC- 00 -1-Q a- 0 .
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)
'/- ., OLO tS. S fix. Pki.
Signature of authori representative Address of authorized representative (number and street,city,state,, d ZIP code)
__ ___-.., ..a ,-,uk-ii iiiuntn alter'that.