Disabilty_Dishon APPLICATION FOR BLIND OR DISABLED PERSON'S CO NTY TOWNSHIP YEAR
A DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R13/1-20)
" 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 Dece 1 and filed or p-d'stmarked 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. in Os j...1 ___...,
Name of applicant(owner or contra uyer)
Is applicant the sole legal or eq ilt•le owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
A1/4YRS 0 No
If name on record is different than at o applicant,indicate below:
Name of contract selIF ILED
Address of contract seller(Eger JnolstraWy,state,and ZIP code) Is heReroapieprtyropinequestion:
Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind esi gegryN it ektryx et)iTo R Is applicant disabled and u ble to ngage in any substantial gainful activity
as defined in IC 6-1,1-12-11(d)?
0 Yes No AYae El No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding oaten ar y r
exceed$17,000?
AYes 0 No 0 Yes DK
Taxing district KeyLegal description Record number(contract) Page number(contra°)
02'3 .
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city state,and ZIP code)
X.
ignature of aut d representative
Address of authorized representa we (number and street,city,state,and ZIP code) -3n,
Social Security
Notice of Award
8
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0000310 00023038 2 MB 0.450 0324M3MCS6PI T158 P16
KERRY G DISH ON
328 W SPRUCE ST
PRINCETON, IN 47670-1246