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Disabilty_Maulden Reset Form ix,/ii'ci, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR s�i1t - ' DEDUCTION FROM ASSESSED VALUATION 7 State Form 43710(R14/9-24) ,f Prescribed by the Department of Local Government Finance SOr) C) 22 Zar 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, signed, and filed by January 15 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) (mt ircuii, , • s. 0400, br) Is applicant the sole legal or equitable owner. If No, what is his/her e artere if owned with someone other than spouse,indicate with whom Yes 0 No I. If name on r r is different than that of applicant, indicate below: SEP 292025 Name of Contract Seller (tiii('Attl a Address of Contract Seller (number and street, city, state, and ZIP code) GI B AN COUNTY AUDI-b a Property in Question: P: 'eat Property ❑ Annually Assessed Mobile Home jIC 6-1.1.7) Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to I v• in substarrbal any gainful actoicy as defined in IC 6.1.1.12.11(d), Yes o Yes ❑ No Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year ex $17,000? Yes E No 0 Yes Of Taxing District ey Number I Legal Description Record Number(contract) Page Number(conk 0 2/S 6 - \2_ -\s- [ 03 ^00L\ ‘,\ 340 - 022 . r I/We c rtify under penalty of perjury that the above and foregoing information is true and correct. Signat of Applicant Address of Applicant (nu and street, city, state, and ZIP code) /ii / M dab.14.---v Grc\- 1 a ‘V 1 •\ %e% -sA\49i Signature of Authorized Repr sentative Address of Authorized Representative (number and street, city, state, d ZIP code) Notice of Award SADONA M MAULDEN • 4 CENTRAL DR 1DECATUR, IL r62526-4588 lilt,,,,,,III1IIIIIIIIIIIIIIIl1Il1l1111I1I11I1II1111I11Illllll You are entitled to monthly disability benefits beginning September 1999. s QieS© C See Next Page N ov � it0R