Disabilty_Crisp .M� .,, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
'% ,: DEDUCTION FROM ASSESSED VALUATION 1 1
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s` `' State Form 43710(R13/1-20) �\0 _ 1
' ''. Prescribed by the Department of Local Government Finance (.9k��� Q
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
Name of applicant(owner or contract buyer)
env\I�etr Crk 5•cp
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:
es ❑ 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:
[-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)?
11-Y--es D No L 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?
,-----res ❑ No ❑ Yes ❑ No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
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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Signa a of auth rizeq'r�preSentative 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)
-52� CrIsf FILED
Name of contract sellerr
Taxing district DEC 2 7 2022
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Key number/legal description 6r124C-/1-/Lee a.v YLL. Q/
aO- - cv r &' -o GIBBON COUNTY AUDITOR
Signature of County Auditor Date signed(month,day,year)
/yi, w0 a ka-A-44. I a/-.?-7/e
Social Security Administration
Retirement, Survivors and Disability Insurance
Notice of Award
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JENNIFER CRISP
8350 S 550 W
OWENSVILLE, IN 47665
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