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Disabilty_Mossberger ��s enm. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR DEDUCTION FROM ASSESSED VALUATION n 2 Sao! State Form 43710(R13/1-20) C 01/'/ © . 2 � ' Prescribed by the Department of Local Government Finance J File Mark Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. (A .-2.0—ZC)ZZ ( INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located. Ka-kg_ Qom` ry\ Filing Date: Form must be completed and signed by December 31 and filed or Name of applicant(owner or contract buyer) 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: ❑ Yes ❑ No If name on record is different than that of applic Illi e below: Name of contract seller V. ...." 8-3110.041 o �n• Address of contract seller(number a��s cit�toMllP�de) I'ty(e property in question: i/ .�p.J �[y Real Property ❑ Annually Assessed O0.'. y / Mobile Home(IC 6-1.1-7) Is applicant blind as defined in 1104 1 1(1)? (fa /tit,J� Is applicant disabled and unable to engage in any substantial gainful activity 0 `�"'"' as defined in IC 6-1.1-12-11(d)? XYes ❑ No Yes ❑ No Is the property used and occupied primarily for his/her residence? /// \\\ Does the applicants taxable gross income for the preceding calen r ar exceed S17,000? L Yes ❑ No ❑ Yes X/oTaxing district Key number)))/Legal description Record number(contract) Page number( ) O 2� Z 6 -t o --3 6 -4 00-000. O _� --c72-k . 1/We certify under penalty of perjury that the above and foregoing information is true and correct. Signature of applicant Address::::::: ::::: : et city,state,and ZIP code) 6 siyn t of aatAddress tative (number and street,city,state.and ZIP code) y