Disabilty_Quinlin ..,... , APPLICATION FOR BLIND DIS LED)ERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSEDLUAi ION
State Form 43710(R13/1-20)
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ees Prescribed by the Department of Local Government Finance .-OatV4:(P \, ,„ oRs c-20 2
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)
Is applicant the sole legal dr.e.juitable owner? If No,what is his/her exact s fit owned with someone other than spouse,
dicate with whom:
Yes El No
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If name on record is different than that of pplicant,indicate below:
ifttk\\51%-0filfrii 2021
Name of contract seller
GIBSON :.,..........,'..
Address of contract seller(number and street,city,state,and ZIP code) I th roperty in question:
Real Property 0 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)?
[I],Yes klo kes ril No
Is the property used and occupied primarily for his/her residence? , Does the applicant's taxable gross income for the preceding calendar ar
exceed$17,000?
K es D No Li Yes tract)
Taxing district Key num er Legal description Record number(contract) Page number co tract)
CA DID-12-vi- KA-00 0 . b 01- -,oz
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
nt Address of applicant (number and street,city,state,and ZIP code)
Signature of applica
CM, ,S Ail:A-v(14.
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
,,WuIO s.,et a tsenent venncauon Letter
Social Security Administration
Date: July 06, 2018
BNC: 18B1777A56728
REF: A
ROSEMARY QUINLIN
911 S ADAMS STREET
PRINCETON IN 47670-2701
)
https://secure.ssa.gov/myCYB/start 1/3