Disabilty_Neufelder ,.�, APPLICATION APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
7:� DEDUCTION FROM ASSESSED VALUATION
' i' State Form 43710(R13/1-20) (/' 1I,� ��t O ��
Prescribed by the Department of Local Government Finance
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.
Name of applicant(owner or contract buyer)
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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//:
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res No (Kr/�bef'!a4 V /Ve✓C'el it..--
If name on record is different than that of applicant,indicate below: J
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
Lg-fre-al 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 engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)? ,—,�
❑ Yes No Is res ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
es ❑ No Yes L'SNo
Taxing district Key number/Legal description Record number(contract) Page number(contract)
v ni O v‘ .24-I -oq-Yoo-o00. G Dq- oaS
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)
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Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day,year)
/4GrK E lieu -p- A x FILED
Name of contract seller
APR 2 8 2022
Taxing district
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Key number/legal description C IBSON COUNTY AUDITOR
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Signature of County AuditorLDate signed(month,day,year)
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Social Security Administration
Retirement, Survivors and Disability Insurance
Notice of Award
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