Disabilty_Richardson �..'1- ,, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
4 s DEDUCTION FROM ASSESSED VALUATION
� 1. State Form 43710(R13/1-20) I b 50 ri ?('\AC.e 11 a,
', Prescribed by the Department of Local Government Finance ��JJ
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.
/
�arC�\\ �e b10 cc_ F, c h say,
Is applicant the sole legal or equitable owner? er exact share of interest? If owned with someone other than spouse.
indicate with whom:
EI-Ire-s— El No
If name on record is different than that of applicant,indicate below:
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
teal 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 D'// Yes ❑ 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 ❑ No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
RI NCI,e.-{ovi a6, -0 - 1 D O /. r)( O - 6,,,2�
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant L_ Address of applicant (number and street,city,state,and ZIP code)
Signature of authorized12
eentative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Date filed(month,day,year)
Name of applicant
ccC-ce ;� -\ e« p.; c o so v, FILED
Name of contract seller
SEP 6 2022
Taxing district /
V \��� VI i�.2Z.�i.�C a...YY 6;.4)
Key number/legal description GIBSON COUNTY AUDITOR
—)a- 07—/ Q —00 1. aC D -oa
Date signed(month,day,year)
Signature of County Audito L��/, /1 �J�
Social Security Administration
Retirement, Survivors and Disability Insurance
Notice of Award
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