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.Mw�>.9. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
�x t+�•4s DEDUCTION FROM ASSESSED VALUATION
_' _5 State Form 43710(R13/1-20) (/_' •
t,., D ��
Prescribed by the Department of Local Government Finance v t •J Soh 1 i\mac'
e16 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 a.- -'•ned by December 31 and filed or postmarked by the following January 5 of the calendar year in which the
property taxes are firs • e and•ayable.
See reverse side for additional instr tigns and u- fications.
Is applicant the sole legal o equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
Li 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) 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)?
❑ Yes No I t-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$17,000?
al-,es ❑ No ❑ Yes No
Taxing district Key number/Legal description Record number(contract) Page number(con r ct)
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant , ,. Address of applicant (number and street,city,state,and ZIP code)
-77,/e,. /-jtt/f/9,4" ?3U$ L.Vcrv‹, c� P`i n tom, N '{7�70
Signature of authorizedrepres rtfative 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)
A\"(� -"nev' L a- ' - --
Name of contract seller FILED
Taxing district ■1�_
FEB 0 7 2023
v r-•iNc_.e.Iry v‘
Key number/legal description 1ZAL-. /) d/YLL 7td)
,PG,-I a-6 7_ Yv.� - o^I r}-7 it _D. GIBBON COUNTY AUDITOR
Signature of County Auditor (./CJ (7r r �l Date signed(month,day,year)
l' 9 tO . .n/ 2-11/7 /a-3