HomeMy WebLinkAboutDisabilty_Matthew .0._t5., . APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
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4..,-.,!,3! State Form 43710(R13/1-20) \To n 00 t
-4, Prescribed by the Department of Local Government Finance
File Mark
LInformation 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 Jan t 5 h cale ear in which the
property taxes are first due and payable.
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Name of applicant(owner or contract buyer) 4IA Y 2,,„
v 202,
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1/47-72&-e-eczei (2.- 4.4-t-A• cs.. 34---4.,,,4....
Is appli nt the sole legal or equitabl owner? is/her exact share of interest? If owrinPiatIV ireodgg2t0144ere,
indicate with w v :Nry
LI Yes El No tibn-OF?
If name on record is different than that of applicant,indicate below:
7‘2,4,04a...4
Name of cant ct seller
Address of contract seller(number and street,city,state,and ZIP code) Is th property in question:
Real Property Ei 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)?
[1]Yes -El-No ' Yes Ell 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?
;4es E:=1 No 0 Yes TS.J:slo
LW Taxing district Key number/Legal description Record number(contract) Page number(contract)
'&40--L4Y'-------2- e7Z-.ao-//-Zor-4-a .) Yo--a---6 /
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applican Address of applicant (number and street,city,state,and ZIP code)
0k(4 6 4) C:11IN 14-r(io
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
51.911-(ain latkA44tECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND I DISABLED PERSONS
Nam " Date filed(month,day,year)
Name of ontrac seller TILED
Taxing district 4/Ay 2 u,. 2021
,44-4-74,9e
ey number/legal descri‘n G>/"1"14er-eti
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Signature of County Auditor Date signed(month,day,year)
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