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o�—STAr. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
_ `. DEDUCTION FROM ASSESSED VALUATION �` ma� '� a
l� ) State Form 43710(R13/1-20) A. J a
ie✓' Prescribed by the Department of Local Government Finance (`•
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 oirie for ad itional
interest? IfbwrrE■�dyrwith someone other than spouse,
whom:
s ❑ No F IL
If name on record is different than that of applicant,indicate below:
SEP 1 6 2022
Name of contract seller
lk i 22 Gr// a.1/,�azk ai
v GIBBON COUNTY t s mepf0•- in question:
Address of co trractact s seller(number and street,city,state,and ZIP code)
eal 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 es ❑ 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)
teqQ,43-9S0-1•C*1043 .12 -1-1-ate - --1•00 - 000 -aoa -o. . 1
i/We certify under penalty of perjury that the above and foregoing information is true and correct.
10 ± c
-pplicant Address of applicant (number and street,city,state,and ZIP code)�� ck) . . ( p-i.- . -
Signature o authorized represents i Address of authori representative (number and street,city,stake,and ZIP code)
-> : _q____J FILED
Name of contract seller
ti--\ SEP 1 6 2022
Taxing district(1Z, \ ,
a,`Q `� ' C1 ``OO 7L"D� o a - o I . GIBSON COUNTY U TOR
Key number///legal description
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Signature of County Au id tor" _ Date signed(month,day,year)
-"�,•,,��—Q . pc _- -q D / �i 1 s) - -7____-2__-.
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