Disabilty_Robling F1
f.,0 Ci
'"%�4s DEDUCTION FROM ASSESSED VALUATION N ' NSHIP YEAR
'�`Y - :ii,fr ' State Form 43710(R13/1-20) m1� '
,e16 Prescribed by the Department of Local Government Finance DEC 2 9 2020 O '2-O-1,o .
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the propertalic n I. q
Filing Date: Form must be completed and signed by December 31 and filed or postmarked b Bhe following January AUDITOR me calendaryear 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)
Is applicant th ole legal or equitable owner? If No, t is his/her exact share of interest?
If owned with someone other than
spouse,
with whom:
Yes Vl No ' 1v2';14& 4!n4'
If name on record is differenfthan that of applicant,indicate below:
Name of contract seller
•
Address of contract seller(number and street,city,state,and ZIP code)
Is the 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)?
❑ Yeso '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$17,0,00?
]Yes ❑ No ❑Yes ] No
Taxing dist c Key number/Legal description
Record number(contract) Page number(contract)c
A. I^i,L -dS -.3ai_o03 - as -03. 8
I//W�e certify under penalty of perj' (47ury that the above and foregoing information is true and correct. •
Sighatdre of awn"- li -' Address of applicant (numb r and street,city,state and ZIP code)
eiI (3—) L,OLswc.46in o- sgSignat re of authorized representative Address of authorized representative•(number and street,cit w,and ZIP code)
L011°
a • When the back SS1 paymen�5
N •
payment, including any money :the State,tells;us,to.,pay,,,itsxresidents, ,we,- , •
g generally must pay this money in installments. Usually, this amount is
1' ' .also the limit for what we.can pay'in the -first 9 secondJinstalament - .
payments: „If a third;installment isEneeded, :it.will be.-for the, balanc,e.,.of
the;back payments,'after we Jhay.e paid:the fir- t ,and second installments.
•
•
,' 'L
See Next Page
SSA•L8165
