Disabilty_Downs APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
4.0 ?r--*:‘ DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R13/1-20) Gson 028 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 tmarked 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. -cations. .
Name of applicant(owner or contract buyer)
Downs, Robert L
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:
123 Yes El No
If name on record is different than that of applicant,indicate below:
FILED
Name of contract seller
NOV 3 0 2.021
Address of contract seller(number and street,city state,and ZIP code) Is the property in question:
./4-446;n„..) 10 Real Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
AUDITOR
Is applicant blind as def9MS:MP792-72111(T17? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
66 Yes D No [2] Yes 0 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?
[Z]Yes 0 No El Yes WI No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
028 26-12-07-201-001.177-028
inniz --rtify under penalty of perjury that the above and foregoing information is true and correct.
signat -e• •icant
.
Address of applicant (number and street,city state,and ZIP code)
x
210 E Spruce St, P'ton, IN 47670
lignat re• authorized representative Address of authorized representative (number and street,city state,and ZIP code)
tisi
) ). 'T•D• r/dz.z._I e r.5-k)r, ...
Name: Robert Downs Jr.
Address: 210 E Spruce St. Princeton, IN 47670
•
Best corrected vision:
OD (right eye) HM OS (left eye) 20/200 OU (both eyes 20/200
Width of Visual Field (in degrees):
Specific eye condition(s):Glaucoma, Macular degeneration, corneal transplant
CERTIFYING AUTHORITY:
I certify that Robert Downs Jr. is legally blind in both eyes
as specified in the federal definiti q ted ove.
(