Disabilty_Crase .M .,,* APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
7s DEDUCTION FROM ASSESSED VALUATION ^1 0�� ^n 9
_' i' State Form 43710(R13/1-20) t on �'V C_C_
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
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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:
❑Yes ❑ 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) 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 unable to engage in any substantial gainful activity
/^ as defined in IC 6-1.1-12-11(d)? ♦ /
El Yes LJp No /r�_�7h Yes El No
Is the property used and occupied primarily for his/her residence? / \ Does the applicants taxable gross income for the preceding calen(ar year /
exceed$17,000?
❑ No Yes No
Alc'es
Taxing district Key nuLegal description Record number(contract) Page n ber(c ntr ct)
0 Zg . 26 - 12-01-LIO1-oo2 .OSIj b221 •
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) _�1+v ,.,^
•
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
Date filed(month,day,year)
Name of applicant
CY-ok..._yt . FILED
Name of contract seller
DEC 1 3 2022
Taxing district O / o 'L --, 'Y L`
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•
GIBSON COUNTY AUDITO
Key number/legal description
26- - 12- 0 "q- -k-io\ - 0 02 . O 1-0 aS .
Signature of County Auditor ' / Date signed l(1 onfh�day,year)
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ivtICHAEL CRASS
316 S GIBSON ST
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PO BOX 6.13
PRINCETON, IN 47670-2i 14
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