Disabilty_White (2) �•TM. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
- State Form 43710(R13/1-20) �C -�-'(�el
GSOn 020 2021
�`---a14�1' 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: F ty Form
must be taxes are comfirstpleted
and signed a and payable.December 31 and filed
Na - • --- - t(owner or contract buyer) ` �� 4
W hite, John I) JR/Jenny E ``
_-_ _ _- - • -legal or equitable owner? o,wh hi - ? If owned with sot�q�e other than spouse,
--- " •� indicate with wh "-'
® Yes ❑ No j
✓^If name on record is different than that of applicant,indicate below: ".
N S w 2022
Name of contract seller
0/as
Oty Oo H Y �.,� i,
Address of contract seller(number and street,city,state,and ZIP code)
Is the property in question: A(Jo 4
m Real Property ❑Annually
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 No I 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 ® No
Key number/Legal description Record number(contract) Page number(contract)
Taxing district
020 26-04-25-300-000.587-020
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant I Address of applicant (number and street,city,state,and ZIP code)
r ' Y�../�-.ram-sc--,
109 W Blue Jay St, Patoka, IN 47666
Signal �,of autho`� representative Address of authorized representative (number and street,city,state,and ZIP code)
`�Ttoster UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
fr Washington,DC 20415
Fo
gip, April 13, 2021
CSA: 9 239 053
JOHN WHITE JR
109 W BLUEJAY ST
PATOKA, IN 47666
* {- -
Dear JOHN WHITE JR,
U.S.OPM,Retirement Services,PO Box 45, Boyers PA 16017• Retire(7u opm_gov•www.ServicesOnline.opm.gov• 1-888-767-6738