Disabilty_Skelton (2) .M�^±_•., APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
A. ,R,. DEDUCTION FROM ASSESSED VALUATION
z'' 6)- State Form 43710(R13/1-20) Q U�'� Vv
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ems' 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.
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.
Na of applicant�ner or con'_- •uyer)
V\CANI
‘ n . fIrlci ,_9/ .a)t'o 0
I -•plicant the sole le. -q itab at is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑Yes ❑ No FIT ,ED If name on record is different than that of applicant,indicate below:
Name of contract seller - _
!�22,- azi a.LY
Address of contract seller(number and street,city,state,and ZIP cooG113bON COUNTY AUDITOR I th property in question:
Real 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 una le to gage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑ Yes ❑ Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding cale da ear
Xes
exceed$17,000?
❑ No ❑ Yes No
Taxing district Key numgal description Record number(contract) Page numbe (cont ct)
POIF - Z 6— \2-ro7 - -0 03 0oo ozy .
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature f a nt Address of applicant (number and street,city,state,and ZIP co7je)s
, 0,-, Y
Signature of authorized representative Address of authorized representative (number and scree oily,state,and ZIP code)
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