Disabilty_Robb -�R,,.
0APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
/_ DEDUCTION FROM ASSESSED VALUATION
_ - State Form 43710(R13/1-20) • c'1-eeac�',C0 t
oif 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
See reverse side for additional instructions and qualifications. Q-. t C o� r(Da-- L.1[1.,�tL. -
Name of applicant(owner or contract buyer) `"
`-bG.,,d Robb
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) Is the propertyin question:
1 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 ❑-t9 II-fes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000?
[]Ses ❑ No i ❑ Yes - —PM
Taxing district Key number/Legal description Record number(contract) Page number(contract)
R.-G..^CSCo C96-l3-iq-fiber- oco. o to-c06
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signaturei of applicant Address of applicant (number and street,city,state,and ZIP code) ^� �/
!)Q J W, C2 b S. S 3" " f `C C..I.GI S C 0 J-� ` 7 4. Yq
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)
Name of contract seller FILED
DEC 1 2022
Taxing district
�'�Q✓\CaSCO G BSON COUNTY
Key number/legal descriptionAUDITOR
'12-(3-1q-DO --IDCC) ' auto - 6D5
Signature of County
// Date signed(month,day,year)
q") 1 �� 4 (a/( /a--D-
11111
DATE: OCTOBER 07 , 2022
Disability Update Report APFORM PROVED
FOR SSA USE ONLY
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