Disabilty_Richter APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
)1 State Form 43710(R13/1-20)
„> r Gibson Johnson 2021
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)
Gregory Richter
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:
Yes No
If name on record is different than that of applicant,indicate below:
Name of contract seller
N/A
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)?
❑Yes i I No ®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?
Yes ❑ No ❑Yes I No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
Johnson 26-22-15-300-000.377-024
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)
:14:k7
3366 W 1300 S, Haubstadt, IN 47639
Signature of a orized 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)
Gregory Richter FILED
Name of contract seller
N/A MAR 1. 0 2021
Taxing district Johnson %kizdzad a vira,&ana)
Key number/legal description GIBSON COUNTY AUDITOR
26-22-15-300-000.377-024
Signature of County Auditor Date signed(month,day,year)