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Disabilty_Ramsey , Si-2-IA 17:2— " • �—_. , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR ,4. 4s DEDUCTION FROM ASSESSED VALUATION s.� i' State Form 43710(R13/1-20) „^ � • 'D ^2_ r '� Prescribed by the Department of Local Government Finance {1 Y 1\ L 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 ^ Name`o app licant plicant(owner or contract t(uy r)[ of E FILED Is applicant the sole legal or equitable owner If No, hat is his/her exact share of interest? If owned with someone other than spouse, indicate with whom: Yes ❑ No MAR 2 4 2022 If name on record is different than that o applicant,indicate below: !7124G/iacC &J/Yetend) GIBSON COUNTY AUDITOR Name of contract seller Address of contract seller(number and street,city,state,and ZIP code) Is t e perty in question: eal Property ❑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 a gage in any substantial gainf I activity as defined in IC 6-1.1-12-11(d)? ❑ Yes No Yes ❑ No Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding cale ar ar �(/ exceed$17,000? LQI Yes ❑ No ❑ YesAoTaxing district Key nu ber Legal description Record number(contract) Page number(c O 22 - `6.\-A--_ 12_7"'t--p 0 .1132 07.3- . I/We certify under penalty of perjury that the above and foregoing information is true and correct. ySignature of applicant Address of applicant (numb nd street,city,state,and ZIP code.Af° e3A714-41 . Ci Y \-- Si— GI„me -N 66 Signature of authorized representative ddress of authorized representative (number and street,city,state,and ZIP code) L `aL sec-G, /, S�'=, Social Security Administration IIIIIII Benefit Verification Letter l7STR' cn I4hiri4iiI4iIII4hU11.i11l11rli4i1111i111111n1.1111."1 TOMI DENISE RAMSEY