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APPLICATION FOR BLIND OR DISABLED PERSON'S TUNTY TOWNSHIP YEAR
5.i DEDUCTION FROM ASSESSED VALUATION /� C p n 2 s' i' State Form 43710(R13/1-20) ',y.,.3 O Q _)O
\ ' Prescribed by the Department of Local Government Finance .^ (`` O` LLLJJJ
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 postmarked 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. tie-,e- i S row-t-- A c_ T"ot
Name of applicant(owner o tract buyer ....-------.
r)eA J 1 ir\it-- CGati
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If o ed with someone other than spous
Xesindicate with whom:
❑ No
If name on record is'different than tpplicant,indicate below:
Name of cciftact#IIel „El )
Address ofccontkip4llel(r3nflEY'2dd street,city,state,and ZIP code) Is hem roperty in question:
GULLeal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
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Is appl�fU 1V 17l �1)? Is applicant disabled and unable to engage in any substantial gainful activity
GIB$ ko
as defined in IC 6-1.1-12-11(d)?
ElYes Aes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calen r
,,��``,,//.. exceed$17,000? XN0
Aes ❑ No ❑ Yes
Taxing district Key num66//er/ egal description Record number(contract) Page number(cct)
02 - 4-1q-18 302-00o .13.S1-026 .
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 ,d 705 E St , F-1— ,,c), , —3N 1-PC43'
nature of authorized r sentative Address of authorized representative (number and street.city state,and ZIP code)
I
C"°`,5 "teA -
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day,year)
'G\ egApe1 C LA rAa. T��) FILED
Name of contract�eiler \J �.
APR 1 3 2022
Taxing district
GIBSON COUNTY AUDITOR
Key number/legal description
C- 1°I- 1 g -3 02 - 000 .tc3 g -O2 6,
Signature of County Auditor Date si ned( nth,day,year)
Wo. `.tic- CT 11 I3 2.)22- .
Afl Deaconess Clinic Oakland City Family Practice
Oeci,coness 1204 Williams Street
Clinic Oakland City IN 47660-1001
Dept: 812-749-6187
Dept Fax: 812-749-4966
Steve Etherton, DO
ofer-
4,
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frWp.(A.21
RE: Earley, Craig MRN: 1639449 Page 1 of 1'
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